VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Nov. 12, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Criminal History Record Report

Comments:

A monitoring inspection was initiated on 11-12-2021 and concluded on 11-30-2021. The Administrator contacted by telephone to initiate the inspection. The Administrator reported that the current census was 17. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. Two inspectors conducted the on-site portion of the inspection on 11-30-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Staff #2 was hired on 11-09-2021. The Record of Initial Staff Training/Orientation for Staff #2 was also completed on 11-09-2021. However, the Report of TB Screening stating Staff #2 can be considered free of tuberculosis in a communicable form was completed on 11-12-2021.
Plan of Correction:	TB screenings will be completed prior to hire.
Standard #:	22VAC40-73-530-B
Description:	Based on observation and discussion, the facility failed to ensure the doors leading to the outside be unlocked from the inside or secured from the inside in any manner that amounts to a lock. Evidence: 1. On 11-30-2021, upon entering the facility, the front door of the facility requires a code to enter and exit the building. 2. Staff #3 confirmed a code must be entered to come into or leave the building. If the resident is unable to recall the code, Staff #3 acknowledged the resident would be unable to freely leave the facility.
Plan of Correction:	Virginia Sprinkler Company has been to the facility to access current code system. They will be contracted to make access in and out of facility with using a code.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and discussion, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. On 11-30-2021, during a tour of the facility with Staff #3 and Staff #5, two labeled bottles of Ammonium Lactate 12% on the nightstand were observed in Resident #3?s room. 2. During interview, Staff #5 confirmed Resident #3 is dependent in medication administration and removed the items from the room.
Plan of Correction:	Families have been asked to leave all medication, prescribed and over the counter with the nursing staff so it may be dispensed by medication aides. Room audits will be completed by RCC to ensure medications are not in Resident rooms.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #3 provided a list of newly hired staff and dates of hire to include Staff #4 (date of hire on 10-01-2021). 2. Staff #4?s criminal history record report was requested by the Virginia State Police on 10-18-2021; however, the completed report has yet to be received by the facility. A report through the Virginia State Police Central Criminal Records Exchange was completed on 11-17-2021 with the status noted as ?transaction is being processed.? 3. Staff #3 could not provide a criminal history record report for the aforementioned staff.
Plan of Correction:	Criminal Record checks will be completed prior to hire for all employees. Results have been received.