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: Yes

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint 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 complaint was received by VDSS Division of Licensing on 03/25/24 and 04/01/24 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services and Buildings and Grounds 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: 11 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 The evidence gathered during the investigation supported some but not all of the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #1 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Levothyroxine 2.The record for resident #2 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Levothyroxine 3. The record for resident #3 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Synthroid 4. The record for resident #4 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Propranolol 5. The record for resident #5 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Levothyroxine. 6. The record for resident #6 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medications as prescribed: Levothyroxine; Protinix; Calcium Carbonate Antacid Suspension. 7. The record for resident #7 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Levothyroxine. 8. The record for resident #8 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Lispro Sliding Scale Insulin. 9. The record for resident #9 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Omeprazole. 10. The record for resident #10 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Levothyroxine. 11. The record for resident #11 contains a medication error report that documents on the day of 03/04/24, the resident did not receive the following medication as prescribed: Levothyroxine 12. The record for resident #13 contains a physician order dated 12/06/23 to receive ?Eliquis, Give 1 tablet by mouth two times a day.? The resident?s medication administration record and progress notes did not include documentation the resident received Eliquis, 2 times a day, as prescribed the dates of 03/19/24 through 04/09/24.
Plan of Correction:	In respect to the specific resident/situation cited: All residents noted in this violation had a medication error report completed per the medication management plan to include notifications to the resident's MD and RP on the date of the missed medication, March 4, 2024. In respect to how the facility will identify resident/situations with the potential for the identified concerns: Ensuring each licensed team member administering medications has the proper credentials to access the EHR, EMAR, and document clinical notes before taking an assignment administering medications. LPNs and RMAs were educated on the importance of medication administration and the documentation thereof. LPNs and RMAs will be educated on paper documentation of medication administration if electronic access is unavailable. LPNs and RMAs will be educated on the medication management plan. Ongoing routine MAR to Cart audits are being completed. Our pharmacy (Omnicare) will also be completing a 100% MAR to Cart audit to include an outside party for ensuring compliance. With respect to what systemic measures have been put into place to address the stated concern: Human Resource Manager educated on how to obtain the specific credentials for each employee and their role so that the employee can perform their job duties to the standards of Virginia Department of Social Services. Clinical employees will have a meeting with the Director of Clinical Services at the end of their training to ensure that all training, tools, and resources needed to succeed in their role have been provided.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. The records for residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 contains a medication administration record that includes ?resident will receive rounds every 2 hours during the night to assess for safety. The records for the residents did not contain documentation 2-hour rounds were documented on 03/04/24 during the time of 12:00 am through 6:00am.
Plan of Correction:	In respect to how the facility will identify resident/situations with the potential for the identified concerns: Ensuring each clinical staff member has the proper credentials to access and document clinical notes. Clinical staff educated on the importance of Q2 hour rounds and the documentation thereof. Clinical Staff members will be educated on paper documentation of care provided should the EHR be unavailable. With respect to what systemic measures have been put into place to address the stated concern: Human Resource Manager educated on how to obtain the specific credentials for each employee and their role so that the employee can perform their job duties to the standards of Virginia Department of Social Services. Clinical employees will have a meeting with the Director of Clinical Services at the end of their training to ensure that all training, tools, and resources needed to succeed in their role have been provided.