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: July 8, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/08/2024 from 9:44a.m. until 12:38 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 6/17/24, 6/28/24 and 7/1/24 regarding allegations in the area(s) of: Staffing And Supervision, Resident Care And Related Services and Safe and Secure Environment. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed:0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: 2 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on the onsite record review, it was determined that the facility did not ensure The Individualized Service Plan (ISP) shall be reviewed and updated as needed for a significant change of a resident?s condition. Evidence: 1.Resident #4 was discharged from the hospital on 06/24/24. The resident?s discharge included a physician?s order dated 06/24/24 to ?change diet to puree?. 2. The Individualized Service Plan (ISP) in the record for resident #4 was not updated to reflect the change in diet authorized on 6/24/24. 2. Staff #1 confirmed that the Individualized Service Plan (ISP) was not updated to include the ?puree? diet listed in the physician?s orders.
Plan of Correction:	Plan of Correction: In respect to the specific resident/situation cited: The Individualized Service Plan for Resident #4 has been updated to reflect the change in diet authorized on 6/24/2024. This Individualized Service Plan has also been reviewed for accuracy and compliance with the Virginia Department of Social Services standards. In respect to how the facility will identify resident/situations with the potential for the identified concerns: All Individualized Service Plans will be reviewed for accuracy and compliance with the Virginia Department of Social Services standards. In respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services will review all Individualized Service Plans of residents who return to Bay Lake after receiving external clinical care/treatment, in conjunction to any discharge paperwork, to ensure the Individualized Service Plan is accurate, up to date, and in compliance with the Virginia Department of Social Services standards. The Executive Director will develop a plan to ensure the above initiative is completed in a timely manner by a different human resource if the Director of Clinical Services is not present or available. Date to be Corrected: 8/31/2024