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: Oct. 24, 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:

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: 10/24/2024 from 2:15p.m. until 4:30 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 10/21/2024 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: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: 1 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-470-B
Complaint related:	Yes
Description:	Based on the record review the facility did not ensure a resident's need for skilled nursing treatments within the facility shall be met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse. Evidence: 1. Resident #2?s physicians order dated 10/23/24 states ?provide wound care daily to ensure the wound was being cleaned and dressed?. The facility did not have documentation in the residents record of the care by a licensed nurse, or by a home health agency or by a private duty licensed nurse. 2. Resident #2?s MAR reflects that Registered Medication Aide provided wound care on 10/24/24. 3. Staff #2 confirms the Registered Medication Aide completed the wound care as identified by the MAR.
Plan of Correction:	1) All active treatment orders will have notation in the extended sig to state treatment is to be completed by the licensed nurse on shift. 2) Once weekly an internal audit will be conducted for adherence. 3) RMAs will be educated on scope of practice as it relates to treatment orders Identification of individual(s) and/or staff position(s) responsible for implementing the preventative measures Director of Clinical Services or designee Date of Completion 11.4.24 and ongoing Identification of individual(s) and/or staff positions that will monitor the overall POC Acting Executive Director and Director of Clinical Services
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on the record review the facility did not ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. The record for resident #2 contains a physician order for Debrox Otic Solution that includes the following instructions: Instill 1 drop in both ears 2 times per day for ear pain 10/2-10/3. 2. The MAR reflect documentation of administration of the ear drops beginning on 10/4/24(9:00am,5:00 pm), 10/5/24(9:00am,5:00 pm),10/6/24(9:00am,5:00 pm),10/7/24(9:00am,5:00 pm),10/8/24(9:00am,5:00 pm),10/9/24(9:00am,5:00 pm),10/10/24(9:00am,5:00 pm),10/11/24(9:00am,5:00 pm),10/12/24(9:00am,5:00 pm),10/13/24(9:00am,5:00 pm),10/14/24(9:00am,5:00 pm),10/15/24(9:00am,5:00 pm),10/16/24(9:00am,5:00 pm),10/17/24(9:00am,5:00 pm),10/18/24(9:00am,5:00 pm),10/19/24(9:00am,5:00 pm),10/20/24(9:00am,5:00 pm),10/21/24(9:00am,5:00 pm),10/22/24(9:00am,5:00 pm),10/23/24(9:00am). 3. Staff #2 confirms the medication was administered beyond the physician order.
Plan of Correction:	1) An order listing report will be reviewed daily to ensure order entry accuracy into the EHR EMAR. Identification of individual(s) and/or staff position(s) responsible for implementing the preventative measures Director of Clinical Services or designee Date of Initiation 11.1.24 Identification of individual(s) and/or staff positions that will monitor the overall POC Acting Executive Director and Director of Clinical Services
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on the record review the facility did not ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record. Evidence: 1.The record for resident #1 contains a physician order dated 10/18/24 that includes the following instructions: ?apply Silvadene 1% cream to burn site. Cover with Xeroform then with non-stick gauze daily until evaluated by wound care nurse next week.? 2. The record for Resident?s #1 MAR and record did not contain documentation the resident?s burn was ?covered with xeroform then with non-stick gauze daily ?during the dated of 10/19/24 through 10/24/24. 3. Staff #2 confirms the MAR did not indicate the residents burn was ? covered with xeroform then with non-stick gauze daily ?during the dated of 10/19/24 through 10/24/24.
Plan of Correction:	Methods: 1) An order listing report will be reviewed daily to ensure treatment order entry accuracy into the EHR EMAR. Identification of individual(s) and/or staff position(s) responsible for implementing the preventative measures Director of Clinical Services or designee Date of Initiation 11.4.24 Date of Completion 11.4.24 and ongoing Identification of individual(s) and/or staff positions that will monitor the overall POC Acting Executive Director and Director of Clinical Services