1 Inspection Summary
Inspection Reports Summary
Covers 36 inspections · Feb 2021 – Mar 2026Visit Reason
This report covers 36 inspections of Bay Lake Independent, Assisted Living and Memory Care Community between February 16, 2021 and March 20, 2026 by the Virginia Department of Social Services.
Complaint Details
Multiple complaint surveys were conducted, with 22 inspections prompted by complaints. Some complaints were supported resulting in violations, others were not supported.
Findings
Across that history VDSS cited 54 violations under 33 distinct standards. 21 of the 36 visits ended with violations cited and 15 with none. 22 inspections were prompted by a complaint.
Violations (38)
22VAC40-73-460-E: Facility failed to regularly observe residents for changes and document notable changes in records.
22VAC40-73-640-A: Facility failed to have and implement a current written medication management plan including disposal procedures.
22VAC40-73-680-E: Medical procedures or treatments ordered by physician were not provided or documented as required.
22VAC40-73-470-B: Facility failed to ensure skilled nursing treatments were met by licensed nurse or contractual agreement.
22VAC40-73-680-D: Medications were not administered according to physician's instructions and standards.
22VAC40-73-450-F: Individualized Service Plan (ISP) was not reviewed and updated for significant resident condition changes.
22VAC40-73-450-A: Preliminary plan of care was not developed on or within 7 days prior to admission.
22VAC40-73-680-M: PRN medications were not properly labeled with resident's name and stored.
22VAC40-73-680-D: Medications were not administered in accordance with physician’s instructions (multiple residents missed meds).
22VAC40-73-930-D: Facility failed to document two-hour rounds for residents unable to use signaling devices.
22VAC40-73-450-E: ISP was not signed and dated by licensee, administrator, or resident/legal guardian.
22VAC40-73-40-B: Criminal history record report was not obtained on or prior to 30th day of employment for staff.
22VAC40-73-290-B: Facility failed to post name of current on-site person in charge conspicuously.
22VAC40-73-440-A: Uniform Assessment Instrument (UAI) was not completed at least annually or after significant change.
22VAC40-73-150-B-6: Acting administrator exceeded allowed days without licensure application.
22VAC40-73-410-A: Orientation for new residents and legal representatives was not documented upon admission.
22VAC40-73-450-C: ISP did not include description of identified needs based on UAI.
22VAC40-73-260-A: Direct care staff failed to maintain current certification in first aid.
22VAC40-73-325-B: Fall risk rating was not reviewed and updated after resident falls.
22VAC40-73-700-2: No Smoking-Oxygen In Use signs were not posted where oxygen was in use.
22VAC40-73-680-C: Medications were administered outside the allowed time window around scheduled dosing.
22VAC40-73-560-E: Resident records were not kept in a locked area.
22VAC40-73-680-H: Facility failed to document all medications administered including OTC and supplements on MAR.
22VAC40-73-350-B: Facility failed to ascertain if potential resident is a registered sex offender prior to admission.
22VAC40-73-150-C: Administrator failed to oversee day-to-day operations ensuring resident health, safety, and well-being.
22VAC40-73-470-F: Facility failed to secure immediate medical attention for resident after serious injury or condition.
22VAC40-73-640-A: Facility failed to implement medication management plan preventing use of outdated medications.
22VAC40-73-680-D: Medications were administered not in accordance with physician’s order and standards.
22VAC40-73-680-E: Medical procedures or treatments ordered by physician were not provided or documented.
22VAC40-73-930-D: Facility failed to document two-hour rounds for residents unable to use signaling devices.
22VAC40-73-640-A: Facility failed to implement a written medication management plan preventing outdated meds use.
22VAC40-73-680-D: Medications were administered beyond physician’s order dates and times.
22VAC40-73-680-E: Medical procedures or treatments ordered by physician were not provided or documented.
22VAC40-73-450-A: Preliminary plan of care was not developed on or within 7 days prior to admission.
22VAC40-73-930-D: Facility failed to document two-hour rounds for residents unable to use signaling devices.
22VAC40-73-680-D: Medications were not administered according to physician’s instructions and standards.
22VAC40-73-680-B: Medications were removed from pharmacy containers and placed in unlabeled cups.
22VAC40-73-450-F: ISP was not signed and dated by licensee, administrator, or resident/legal guardian.
Report Facts
Violations cited: 54
Distinct standards: 33
Inspections on page: 36
Inspections with violations: 21
Complaint visits: 22
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