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. 20, 2024 and Jan. 2, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Technical Assistance:

22VAC40-73-650

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: 12/20/2024 from 10:10 am to 11:40 am and 01/02/2025 from 11:15 am to 11:35 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two complaints were received by VDSS Division of Licensing on 12/17/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 26 Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: The food supply was reviewed. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-C
Complaint related:	Yes
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. The December 2024 MAR for Resident #1 indicates Resident #1 did not receive the following medications on the following days: 1 dose of Methocarbamol on 12/6/24, 12/7/24, 12/14/24, and 12/15/24, Duloxetine on 12/12/24, 1 dose of Eliquis on 12/7/24, 12/14/24, and 12/15/24, Gabapentin on 12/2/24, 12/3/24, 12/6/24, 12/7/24, 12/9/2024-12/12/2024, and 12/24/2024-12/26/2024, Pramipexole on 12/14/24 and 12/15/24, and Verapamil on 12/14/24 and 12/15/24.
Plan of Correction:	Medication times are currently being reviewed and appropriately adjusted to assure that each medication pass can be appropriately managed per regulatory standard of an hour before/after. RCD or designee will complete regular, random audits of medication pass to ensure medications are being passed within regulatory standards.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident #1 physically admitted to the facility on 10/25/2024 from a skilled nursing facility. 2. The following medications were ordered upon discharge from the SNF and were not documented on the resident?s MAR for administration: Miralax 17gm daily, Voltaren gel, Tylenol 500mg QID, and Iron 325mg daily. 3. The resident?s record did not include a discontinued orders for the medications listed during the onsite inspection.
Plan of Correction:	Medication audits will be completed on all medication administration records to ensure all medications are given as prescribed by physician?s orders. RCD or designee will re-educate staff of medication management policy. RCD/RCC will ensure residents? orders will be sent to the facility and faxed to current MD.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation, the facility failed to ensure the interior and exterior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. The toilet in the bathroom of Resident #2 and Resident #3 was noted to move upon the touch as it was not bolted to the floor.
Plan of Correction:	Area identified with unbolted toilet will be repaired and/or replaced if beyond repair. Maintenance will monitor physical plant ongoing to address any further related issues.