VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Mayflower on Main Assisted Living
409 South Main Street
Lexington, VA 24450
(540) 463-3161

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: May 14, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 5/14/2020 and concluded on 5/15/2020. The Director of Nursing was contacted by telephone to initiate the inspection. The Director of Nursing reported that the current census was 23. The inspector emailed the Director of Nursing a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules, Fire and Health Department inspections, facility fire drill logs and dietitian reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff attended six hours of training in working with individuals who have cognitive impairments within four months of the starting date of employment. EVIDENCE: 1. The record for staff person 1, hired on 11/11/2019, has documentation that the employee only attended 45 minutes of training on individuals with cognitive impairments within their first four months of employment.
Plan of Correction:	Cognitive impairment training will be completed by 5-25-20 by Director of Nursing and will be monitored frequently.
Standard #:	22VAC40-73-325-A
Description:	Based on a review of resident records, the facility failed to ensure that fall risk ratings were completed as required. EVIDENCE: 1. The record for resident 3, admitted on 9/30/2019, has a fall risk rating that lacks documentation of the date of completion to determine when it was completed.
Plan of Correction:	Fall risk assessment will be updated with updated forms by Director of Nursing on 5-18-20.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility to insure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI dated 11/27/2019 in the record for resident 2 has documentation that the resident is disoriented to some spheres some of the time but the UAI is incomplete as it lacks documentation as to which spheres are affected.
Plan of Correction:	UAI will be updated with disoriented spheres by Director of Nursing on 5-18-20 and UAI will be monitored frequently.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has a fall risk rating completed on 4/23/2020 that indicates the resident is a risk for falls. The record also has documentation of the resident sustaining a fall on 4/5/2020. The ISP dated 4/23/2020 in the record for resident 1 does not address the residents fall risk needs.
Plan of Correction:	ISP will be updated by Administrator by 5-20-20 and will be monitored frequently