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:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-300-B
Description:	Based on record review and interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. The information shall be included in the records of the involved residents. Evidence: 1. Staff #1 confirmed that Resident #1 went to the ER on 01/13/2025; however, there was no documentation of this incident in written communication or in Resident #1?s record.
Plan of Correction:	Administrator/designee will continue to ensure written/electronic communication is consistently being utilized by all direct care staff on all shifts as a mean of communication.
Standard #:	22VAC40-73-470-F
Description:	Based on record review and interview, the facility failed to when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention. Evidence: 1. Resident #1 went to the ER on 01/13/2025; however, there was no documentation the resident?s physician, next of kin, legal representative, or designated contact person was notified of the situation and action taken.
Plan of Correction:	All residents who suffer a serious illness or medical condition will be reviewed by the Administrator/designee to ensure that medical attention from a licensed health care professional is secured timely.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview, the facility failed to implement their written plan for medication management which includes methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. On 01/11/2025, Staff #3 indicated at the start of their shift that there was a discrepancy of 2 narcotics (1 of Resident #1 and 1 of Resident #2) upon counting with Staff #2. 2. Staff #3 reports there was physically 1 additional capsule of Resident #1?s 100 mg Gabapentin on the medication cart than the number documented on the narcotic count sheet. 3. Staff #3 also reports there was physically 1 less capsule of Resident #2?s 300 mg Gabapentin on the medication cart than the number documented on the narcotic count sheet. 4. Staff #3 indicated these discrepancies were verbally reported to Staff #4. 5. The narcotic count sheet for Resident #2?s 300 mg Gabapentin capsule captured a discrepancy on 01/11/2025. It indicates there were 3 remaining capsules on 01/09/2025 and 1 remaining on 01/11/2025. Resident #2 was in the hospital the evening of 01/10/2025 and there is no documentation to show what happened to missing dose. 6. There was no evidence a medication aide note was made nor if there was a need of medication disposal despite the facility?s medication management plan policy and procedure to account for the discrepancies noted on 01/11/2025.
Plan of Correction:	Facility will continue to follow the medication management plan. Administrator/designee will work with the Medication Technicians and review the med. management plan as well as the importance of medications being administered in accordance with physician's orders.
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 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 5 occasions (3 doses on 1/1/2025 and 2 doses on 1/2/2025) despite their SBP being less than 130. 2. The January 2025 MAR indicated Resident #1 did not receive the following medications on the following days: Docusate 100 mg capsule on 1/5/2025, Eliquis 2.5 mg tab on 1/5/2025-1/12/2025, Fluticasone spray 1/1/2025-1/12/2025, Lexapro 5 mg tab on 1/7/2025, Midodrine 10 mg tab on 1/6/2025, and Zinc 30 mg tab on 1/6/2025-1/8/2025 and 1/10/2025-1/12/2025.
Plan of Correction:	Medications will be administered in accordance with the physician's or other prescribers? instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.