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: Dec. 12, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/12/2023 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: 37 Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 #:	22VAC40-73-210-B
Description:	Based on record review and interview, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments. Evidence: 1. Staff #1 was unable to provide documentation of 2022 annual training for Staff #4, RMA/PCA.
Plan of Correction:	Staff records will be audited to ensure compliance with the requirement for 18 hours of training annually. Relias online training platform has been implemented and will be audited regularly to ensure compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 12/12/2023, the facility did not have the designated current on-site person in charge posted.
Plan of Correction:	Corrected during inspection. The administrator or designee will verify posting is current and posted in a conspicuous place within the community.
Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. Evidence: 1. Resident #2 (admitted 7/26/2023) and Resident #5 (admitted 11/14/23) both had their comprehensive ISPs completed; however, there was not a completed fall risk rating in the record of Resident #2 and Resident #5.
Plan of Correction:	Current resident charts and administrative files will be audited for fall risk evaluation with updates made as appropriate with ISP reviewed and updated as needed by Resident Care Coordinator or Administrator.
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. Resident #2 admitted to hospice on 9/1/2023; however, there is no documentation of a fall risk rating being completed when the condition of the resident changed in the resident?s record. 2. There was no documentation of an annual fall risk rating completed for Resident #4.
Plan of Correction:	Administrator provided training to Hospice provider on fall risk rating being completed when change of status. All other resident files and charts were audited for fall risk evaluation with updates made as appropriate with ISP reviewed and updates as needed by Resident Care Coordinator or Administrator.
Standard #:	22VAC40-73-330-A
Description:	Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #5 admitted to the facility on 11/14/2023 and did not have a mental health screen completed in their resident record. Resident #5?s record indicated the resident had behavior within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.
Plan of Correction:	The Administrator or designee will ensure that any resident that is admitted to the community with documentation on their H&P or Yes to the Questions on, that within the last 6 months the resident has exhibited behaviors that were indicative of mental illness, intellectual disabilities, substance abuse, or behavioral disorders and the caused or continued to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk will be referred to the community mental health provider if the resident does not have their own mental health provider.
Standard #:	22VAC40-73-610-E
Description:	Based on observation, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition is kept current and readily available to personnel responsible for food preparation. Evidence: 1. The facility was not able to provide a copy of a diet manual containing acceptable practices and standards for nutrition readily available to personnel responsible for food preparation.
Plan of Correction:	Completed during survey. Administrator printed manual, put in binder and placed in Dining Managers office for future reference.
Standard #:	22VAC40-73-680-C
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 following 8 am medications for Resident #1 were not documented as administered on 12/2/2023: Aspirin-Dipyrid 25-200 mg capsule, Lamotrigine 100 mg tablet, Sertraline 100 mg tablet, Nifedipine 60 mg tablet, and Furosemide 20 mg tablet. On 12/3/2023, Januvia 50 mg tablet and Triamcinolone Cream were also not documented on the MAR as administered for Resident #1. Additionally, the following medications for Resident #1 were not documented as administered on 12/5/2023: Aspirin-Dipyrid 25-200 mg capsule (8 pm dose), Blood Glucose testing (8 pm), Lispro Insulin if required (8 pm), Lamotrigine 100 mg tablet (4 pm), and the removal of their Lidocaine patch at 8 pm. 2. Resident #2?s 7 am (2 medications) and 10 am (12 medications) medications were not documented on the MAR as administered on 12/2/2023. The following medications were also not documented as administered on the December MAR for Resident #2: Acetaminophen 500 mg caplet on 12/5/23 (6 pm dose) and Blood Pressure on 12/10/2023. 3. Resident #4?s 8 am (6 medications) medications were not documented on the MAR as administered on 12/7/2023. 4. During a medication observation on 12/12/2023 with Staff #6, Resident #1?s Januvia 50 mg tablet and Tamsulosin .4 mg capsule were not available for administration. Additionally, Resident #2 was administered their 7 am medications (2 medications) at approximately 8:50 am.
Plan of Correction:	Administrator, Resident Care Coordinator or designee will monitor missed meds and audit med carts monthly.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and interview, the facility failed to ensure the MAR include the dosage administered. Evidence: 1. Resident #1 has a sliding scale insulin order which reads to administrator before meals and at bedtime the following units based off the resident?s blood sugar: 201-250 = 2 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, and above 400 = call MD. However, the MAR for Resident #1 does not indicate the number of units administered. 2. Staff #1 acknowledged the resident?s MAR does not include the number of units administered.
Plan of Correction:	The Administrator contacted pharmacy to correct input of insulin administered into the EMAR. Pharmacy has added a feature to document amount of insulin administered.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility, a stackable washer and dryer unit was noted on an entrance to a resident occupied hallway. 2. Two closet doors in Resident #6?s apartment was noted to be leaning against the rack within the closet. 3. A portion of the facility is unoccupied by residents and undergoing renovation; however, this area was accessible and unsecured with noted hazards to include exposed outlets/wiring, exposed plumbing, and debris. 4. Portion of fencing surrounding resident courtyards was noted to be need of repair.
Plan of Correction:	Completed during survey. Administrator or designee will complete daily walk through of community to ensure all projects are marked clearly, facility is in good repair and resident closet doors are on track.
Standard #:	22VAC40-73-950-F
Description:	Based on interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Evidence: 1. Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.
Plan of Correction:	Emergency Plan was reviewed and signed by VPO and Administrator during survey. Plan reviewed and signed. Completed during survey.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. There was no documentation of a fire and emergency evacuation drill conducted from 4/25/2023-8/9/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-C
Description:	Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. The first aid kit was documented to be checked the following day/month in 2023: 7/17/2023, 9/2023, 10/2023, and 11/2023. The facility was unable to provide documentation of the monthly checks for 1/2023-6/2023 and 8/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. The facility could not provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of Correction:	The Administrator or designee will conduct and participate in all staff resident emergency drills every six months. Documenting attendance, mock emergency, date and time.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. There is no completed sworn disclosure in Staff #11?s record.
Plan of Correction:	Administrator will audit current employee files and ensure all new hires will complete a sworn statement of affirmation while competing application process.
Standard #:	22VAC40-90-40-B
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 #5 (hired 03/30/2023) completed 06/14/2023, Staff #7 (hired 03/28/2023) completed 06/28/2023, Staff #8 (hired 09/18/2023) not completed at the time of inspection on 12/12/2023, Staff #9 (hired 09/25/2023) not completed at the time of inspection on 12/12/2023, Staff #10 (hired 10/19/2023) not completed at the time of inspection on 12/12/2023, Staff #11 (hired 08/29/2023) not completed at the time of inspection on 12/12/2023, Staff #12 (hired 08/02/2023) not completed at the time of inspection on 12/12/2023, Staff #13 (hired 11/07/2023) not completed at the time of inspection on 12/12/2023, and Staff #14 (hired 10/03/2023) not completed at the time of inspection on 12/12/2023.
Plan of Correction:	Administrator will audit current employee files to ensure facility?s compliance. The Administrator will ensure all new hires criminal background reports are reviewed prior to the 30th day of employment. If criminal background reflects barrier crimes, employee will be terminated. If criminal background report is not received within 30 days, Administrator will suspend employee, until report is received from VSP.