VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mayfair House Senior Living
901 Enterprise Way
Portsmouth, VA 23704
(757) 397-3411

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Dec. 4, 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 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-450 22VAC40-73-490 22VAC40-73-530

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/04/2024 from 8:45 am to 3:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 27 Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 2 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to complete a resident?s UAI whenever there is a significant change in a resident?s condition. Evidence: 1. Resident #2 admitted to hospice in September 2024; however, the UAI in the record of Resident #2 was completed on 07/18/2024.
Plan of Correction:	Nurse will review and update all residents Care Plans to ensure all dates, ALDs and Hospice services are included.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan should include a description of identified needs and date identified based upon the UAI. Evidence: 1. Resident #2?s UAI (dated 07/18/2024) indicates Resident #2 requires assistance with toileting, transferring, bowel incontinence, wheeling, stairclimbing, money management, and medication administration; however, Resident #2?s ISP (dated 11/03/2024) does not address these needs.
Plan of Correction:	ISP was corrected on 12/05/2024. Residents UAI and Care Plan were revised to match. Nurse will review all care plans and update if needed.
Standard #:	22VAC40-73-680-C
Description:	Based on record review and observation, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. During a medication observation on 12/04/2024, Resident #1 was administered their scheduled 8:00 am medications (7 total) at approximately 9:30 am. Additionally, Fluticasone 50mcg spray was not available for administration. 2. The November 2024 MAR for Resident #2 indicates Resident #2 did not receive the following number of scheduled medications on the following day: 8 on 11/12/2024, 4 on 11/13/2024, 1 on 11/16/2024, 3 on 11/20/2204, and 1 on 11/25/2024. 3. The November 2024 MAR for Resident #3 indicates Resident #3 was not administered Tramadol from 11/09/2024-11/14/2024 as the medication was not available. 4. The November 2024 MAR for Resident #4 indicates Resident #4 was not administered 3 scheduled medications on 11/13/2024. The November 2024 MAR for Resident #4 indicates Resident #4 was also not administered Omeprazole on 11/20/2024 and 11/21/2024.
Plan of Correction:	Nurse/RCC will review and adjust administration times for medications as needed. All RMA?s will be retrained to ensure all prescribed medications are in the building and given within the required times.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident #1 has an order for Famotidine 20 mg tablet to be administered once daily with lunch; however, the medication is scheduled on the MAR and administered for/at 8:00 am. 2. Resident #1 has an order for Midodrine 10 mg tablet to be administered every 6 hours with a parameter to be held if SBP is greater than 130; however, the MAR indicates the medication was held on 9 times in November (3 doses on 11/27/2024, 1 dose on 11/28/2024, 3 doses on 11/29/2024, and 2 doses on 11/30/2024) despite Resident #1?s SBP on those occasions being less than 130.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-950-F
Description:	Based on interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Evidence: 1. The facility could not provide documentation of an annual review of the emergency preparedness and response plan.
Plan of Correction:	The Emergency Plan was reviewed and signed by VPO and Administrator during survey. Plan reviewed and signed by all staff.
Standard #:	22VAC40-73-970-E
Description:	Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills include the items identified in the standard. Evidence: 1. The record of the required fire and emergency evacuation drills from May 2024 to current did not include all the items identified in the standard.
Plan of Correction:	Fire Drills will be recorded on state model form.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. Staff #9 and Staff #10 did not have a completed sworn disclosure in their record.
Plan of Correction:	The Administrator will ensure all new hires complete a sworn affirmation statement prior to their hire date. All staff files have been audited to ensure compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #6 (hired 10/10/2024) completed 11/27/2024, Staff #7 (hired 06/08/2024) completed 11/29/2024, Staff #8 (hired 09/20/2024) completed 11/25/2024, Staff #10 (hired 10/15/2024) did not have a completed report at the time of the inspection, and Staff #11 (hired 10/10/2024) did not have a completed report at the time of the inspection.
Plan of Correction:	The Administrator will audit all employee files to ensure the facility is compliant with criminal background checks standard. Background checks that do not arrive by the 30th day of employment, will result in immediate employee termination.