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: March 4, 2025 , March 13, 2025 and March 17, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 03/04/2025 from 11:05 am to 11:50 am, 03/13/2025 from 11:15 am to 3:25 pm, and 03/17/2025 from 10:15 am to 1:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Four complaints were received by VDSS Division of Licensing on 02/19/2025, 02/20/2025, 03/07/2025, and 03/11/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Background Checks. Number of residents present at the facility at the beginning of the inspection: 26 Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Narcotic medications were counted and documented. Additional Comments/Discussion: All background checks of staff hired from 12/04/2024 (renewal inspection) were 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 #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to implement their written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes and plan for proper disposal of medication. Evidence: 1. Resident #2 has an order for Oxycodone 5 mg tab every 8 hours as needed with a maximum daily amount of 15 mg from 12/29/2024-02/04/2025, 02/04/2025-02/17/2025, and up to 14 days starting 02/17/2025. The January, February, and March MAR for Resident #2 indicate it was administered 22 times. Resident #2 was interviewed and indicated they requested the medication specifically on 02/04/2025, 02/05/2025, and 02/06/2025; however, Resident #2 was told by staff it was not available for administration. Staff #3 was unable to provide the narcotic count sheet for the medication (42 tabs) documented as delivered to the facility on 02/04/2025. 2. Resident #6?s PRN order for Hydrocodone 5-325 mg tab was unable to be located on 03/06/2025. Resident #6 was interviewed and indicates not requesting the medication for administration. The MAR for Resident #6 indicates it was administered once on 03/03/2025. 20 tablets of the medication were delivered to the facility on 02/27/2025 and signed for by Staff #4. Staff #4 indicated the medication included a narcotic count sheet which was placed on the medication cart with the medication upon receipt. In a written statement, Staff #2 indicates they removed the medication from the cart on 03/06/2025 and put in a locked box in the medication room. Staff #5 was interviewed and stated they were working the medication cart on 03/05/2025 when Staff #2 took the medication and narcotic count sheet off the medication cart. Staff #5 believes (based off memory) there were approximately 17 of the 20 tablets within the pack of medication and the packet of medication did not appear to be tampered with or damaged. In a written statement, Staff #1 noticed the medication was not on the medication cart on 03/06/2025. Staff #1 also noted Staff #2 indicated they took the medication and the narcotic count sheet off the cart and into a locked box in the medication room on 03/06/2025. Staff #1 later went to the locked box the medication was in and ?found that the card had been tampered with and was only holding less than maybe 15 pills that had indeed been replaced with Tylenol rather than Hydrocodone.? Upon discovery of this, Staff #1 discarded the pills in the card and the narcotic sheet. The facility was unable to provide or determine where/what occurred to Resident #6?s Hydrocodone tablets.
Plan of Correction:	All RMA?s have been retrained on company policy and procedures, facility medication management policy and procedures, and proper disposal of medication. All RMAs have retaken the RMA refresher course and have been signed off on medication pass, counts and medication disposal and documentation, by RCD, LPN or Administrator.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
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. The January 2025, February 2025, and March 2025 MAR indicated Resident #1 did not receive approximately 41 medications during the period reviewed. Additionally, a total of 12 medications were not administered the morning of 1/16/25, a total of 15 medications were not administered the morning of 2/5/25, a total of 15 medications were not administered the morning of 2/15/25, and a total of 11 medications were not administered the morning of 3/1/25 for Resident #1. 2. The January 2025, February 2025, and March 2025 MAR indicated Resident #2 did not receive approximately 87 medications during the period reviewed. Additionally, Resident #2?s Oxycodone 5 mg tab order indicates it can be administered every 8 hours as needed with a maximum daily amount of 15 mg; however, the narcotic count sheet indicates one dose was administered at 3 pm and then again at 8pm on 02/25/2025 (none documented on MAR), one dose at 8 pm and 9 pm on 03/03/2025 (none documented on MAR), one dose at 6 am and 12 pm on 03/09/2025 (MAR documents 1 administration at 6:28 am), and one dose at 12 am, 4:30 (does not indicate am or pm), and 9 pm on 03/12/2025 (none documented on MAR). Resident #2?s Oxycodone 5 mg tab was noted to still be on the medication cart for administration as of 03/13/2025 despite the order starting 02/17/2025 for up to 14 days (03/03/2025). The MAR documents it was administered 8 times after 03/03/2025. The narcotic count sheet indicates 12 tablets were taken off the medication cart for administration to Resident #2 after 03/03/2025. 3. The January 2025, February 2025, and March 2025 MAR indicated Resident #3 did not receive approximately 92 medications during the period reviewed. Additionally, a total of 13 medications were not administered on 2/18/25 and a total of 8 medications were not administered the morning of 3/1/25 for Resident #3. 4. Resident #4?s record indicates Lorazepam .5 mg tab every 6 hours as needed was discontinued 12/17/2025 and restarted 02/26/2025; however, the narcotic count sheet indicates it was taken off the medication cart for administration 12 times in February 2025 (prior to 02/26/2025) and 2 times after 12/17/2025. 5. Resident #5?s order for Lorazepam .5 mg tab indicates it can be administered every 12 hours as needed; however, the narcotic count sheet indicates a dose of the medication was given at 6pm and 8pm on 02/10/2025. Resident #5?s MAR indicates only 1 dose was administered at 6:15pm on 02/10/2025.
Plan of Correction:	The RCD, RCC, Administrator or designee will audit all community medication orders for medication availability and non-use. Medications will be ordered/discontinued as appropriate. All medication will be reviewed against valid prescription and physicians order and entered the count as needed. Narcotic counting will be performed using ECP?S digital counting feature. The paper counting books has been removed.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on record review, the facility failed to ensure at the time the medication is administered, the facility document on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements. Evidence: 1. The following are days the narcotic count sheet on the medication cart documents staff taking a dose(s) of Oxycodone 5 mg tab off the cart that are not documented as administered on the MAR for Resident #2: 02/18/2025 (2 doses), 02/22/2025 (1 dose), 02/24/2025 (1 dose), 02/25/2025 (3 doses), 02/26/2025 (2 doses), 02/27/2025 (2 doses), 03/01/2025 (1 dose), 03/03/2025 (2 doses), 03/07/2025 (2 doses), 03/08/2025 (2 doses), and 03/09/2025 (1 dose), and 03/12/2025 (3 doses). Additionally, the MAR for Resident #2 indicates 2 doses of the medication were administered on 03/10/2025; however, only 1 tablet was signed off via the narcotic count sheet for administration. 2. Resident #3 has an order for Tramadol 50 mg tab 2 times daily as needed. The January, February, and March MAR for Resident #3 indicate it has not been administered to Resident #3; however, the narcotic count sheet on the medication cart documents staff taking a dose off the cart each evening from 02/27/2025-03/16/2025 (18 doses). Resident #3 was interviewed and confirmed they receive the medication each evening with scheduled PM medications. 3. Resident #4 has an order for Lorazepam .5 mg tab every 6 hours as needed starting 02/26/2025. The January, February, and March MAR for Resident #4 indicate it was administered on 02/27/2025, 03/01/2025, 03/03/2025 (2), 03/05/2025, and 03/10/2025; however, the narcotic count sheet on the medication cart documents staff taking a dose(s) off the cart on 02/27/2025, 03/01/2025, 03/03/2025 (2), 03/04/2025, 03/06/2025, 03/08/2025, and 03/09/2025. Four of the doses are not documented on the MAR for Resident #4 as administered. Additionally, the MAR indicates the medication was administered two occasions (03/05/2025 and 03/10/2025) that the medication is not taken off the medication cart via the narcotic count sheets. 4. Resident #5 has an order for Lorazepam .5 mg tab every 12 hours as needed. The January, February, and March MAR for Resident #5 indicate it was administered on 01/13/2025 and 02/10/2025; however, the narcotic count sheet on the medication cart documents staff taking a dose(s) off the cart on 01/11/2025, 01/13/2025, 01/20/2025 (2), and 02/10/2025 (2). Four of the doses are not documented on the MAR for Resident #5 as administered. Additionally, Resident #5?s MAR indicates only 1 dose was administered at 6:15pm on 02/10/2025 despite two narcotics signed out at 6pm and 8pm.
Plan of Correction:	All RMA?s have been retrained on company policy and procedures, facility medication management policy and procedures, and completing the medication pass within the required time frame. All RMAs have retaken the RMA refresher course and have been signed off on medication pass, counts and medication disposal and documentation.
Standard #:	22VAC40-90-40-B
Complaint related:	Yes
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 11/07/2024) did not have a completed report, Staff #7 (hired 10/10/2024) did not have a completed report, Staff #8 (hired 02/15/2025) did not have a completed report, Staff #9 (hired 12/12/2024) completed 3/16/2025, Staff #10 (hired 2/15/2025) completed 3/16/2025, Staff #11 (hired 1/23/2025) completed 3/16/2025, and Staff #12 (hired 2/14/2025) completed 3/16/2025.
Plan of Correction:	All Criminal Background checks will be completed on or before the first day of employment. The administrator will monitor those that have not been received, daily. Any employee that does not have a criminal background check within 30 days will be terminated.