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: Oct. 25, 2022

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

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: 10/25/2022 from 9:10 am to 2:45 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: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 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 #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. The current certification in first aid for Staff #5 expires 7/2023; however, the certification is through EMS Safety.
Plan of Correction:	CPR/FIRST AIDE Cards will be reviewed on hire to assure the CPR/FIRST AIDE is from an approved source, according to DSS standard. Administrator will be responsible for checking credentials.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. Evidence: 1. Upon review of the resident?s record, Resident #1 fell on 10/16/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record. 2. Upon review of the resident?s record, the last annual fall risk rating for the Resident #2 was completed 02/27/2021. 3. Upon review of the resident?s record, Resident #4 fell on 10/09/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record. 4. Upon review of the resident?s record, Resident #5 fell on 03/17/2022 and 04/12/2022; however, there is no documentation of a fall risk rating being completed after the each fall or annually in the resident?s record. 5. Upon review of the resident?s record, the last annual fall risk rating for the Resident #6 was completed 12/31/2018.
Plan of Correction:	Fall Risk Assessments will be completed on admission, annually, and after each fall. Incident reports will have updated Fall Risk Assessment attached, copy to go in medical chart. We will follow the guidelines of Mayfair House policy. RCC (Residential Care Coordinator) and Administrator will follow up for compliance.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and interview, the facility failed to ensure the MAR include all medications prescribed to a resident. Evidence: 1. Upon review of the resident?s record, Resident #1 received an order on 10/17/2022 for Ondansetron 4mg tablet to be administered every 8 hours as needed for nausea; however, the medication was not listed on the MAR. 2. Staff #2 acknowledged the aforementioned medication was not listed on the resident?s MAR.
Plan of Correction:	RCC will cross check orders to ensure all medication is listed on electronic MAR per physician's order.