VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bay Lake Independent, Assisted Living and Memory Care Community
4225 Shore Drive
Virginia beach, VA 23455
(757) 460-8868

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: April 10, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 04/10/2024 from 10:39 am to 3:28 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 04/03/2024 regarding allegations in the area of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents in the safe secure environment was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did support the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on the record review the facility failed to ensure the orientation and training required in subsection B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #2, date of hire 01/12/204, did not contain documentation of an orientation and training completed within the first seven days of employment.
Plan of Correction:	In respect to how the facility will Identify resident/situations with the potential for the identified concerns: All current employee files will be audited to the Virginia Department of Social Services standard. With respect to what systemic measures have been put Into place to address the stated concern: The Executive Director was re-educated on orientation and training requirements of this section. The Executive Director will review all employee files within seven days of hire to ensure compliance with the Virginia Department of Social Services Standards. Department Heads to be educated on standard 22VAC40-73-120-A to ensure employees in their respective department receive the required orientation and training and that this is documented accordingly. Human Resource manager at time of violation has been terminated and a new Human Resource Manager has been hired. Employee files will be audited periodically to ensure compliance is being maintained.
Standard #:	22VAC40-73-250-D
Description:	Based on the record review it was determined that the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #1, date of hire 3/13/24, contains a risk assessment for TB dated 10/20/23, which is more than 30 days prior to the staff?s hire date. 2. The record for staff #4, hire date 07/10/23, did not contain a risk assessment for TB completed on or within 7 days prior to the first day of work. 3. The record for staff #2, hire date 01/12/24, did not contain a risk assessment for TB completed on or within 7 days prior to the first day of work.
Plan of Correction:	In respect to how the facility will identify resident/situations with the potential for the identified concerns: All current employee files will be audited to the Virginia Department of Social Services standard. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director will review all employee files prior to the employee coming in contact with residents to ensure compliance with the Virginia Department of Social Services Standards. Human Resource manager attime of violation has been terminated and a new Human Resource Manager has been hired. Employee files will be audited periodically to ensure compliance is being maintained.
Standard #:	22VAC40-73-670-1
Description:	Based on the record review the facility failed to ensure each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. The facility?s incident report dated 04/03/24 documents ?staff #1 was hired as a Med Tech without a valid MedTech License. Staff #1 passed medications to memory care residents.? 2. The record for staff #1, date of hire 03/13/24, did not contain documentation of a license to administer medications. 3. The medication administration records for residents #1, #2, #3, #4, #5, #6, #7, and #8 includes documentation medications was administered by staff #1 during the month of March 2024:
Plan of Correction:	In respect to the specific resident/situation cited: Staff #1 has been terminated from Bay Lake Retirement Community. In respect to how the facility will Identify resident/situations with the potential for the identified concerns: All current employee files are to be audited to the Virginia Department of Social Services standards. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director will review all employee files priorto the employee coming in contact with residents to ensure compliance with the Virginia Department of Social Services Standards. Human Resource manager at time of violation has been terminated and a new Human Resource Manager has been hired. Ongoing licensure audits are being completed to ensure all licensures/certificates are valid and in compliance with the Virginia Department of Social Services Standards.