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 10, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 05/10/2024 9am until 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/01/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-B
Complaint related:	Yes
Description:	Based on resident record review and staff interviews, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training. EVIDENCE: 1. The record for resident 1 has documentation that the resident has a supra pubic catheter. The May 2024 medication administration record for resident 1 has documentation of staff initials for the cleaning of resident 1?s catheter site daily. In an interview with staff person 1 on 05/10/2024, staff person 1 expressed that staff records do not have documentation of receiving training in supra pubic catheter care.
Plan of Correction:	Administrator scheduled staff training on suprapubic/foley catheter for all direct care staff on 5/29/24. Administrator will ensure that all new hires receive the training as well as ongoing renewals.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were updated as needed for a change in a residents condition. EVIDENCE: 1. The record for resident 1 has a Do Not Resuscitate order dated 02/09/2024. The record also has a physician order signed on 01/15/2024 for resident 1 to have a diabetic diet. The ISP dated 07/31/2023 does not address these identified needs.
Plan of Correction:	DNR/Diabetic diet added to ISP on 5/11/24. Administrator will conduct more thorough reviews to ensure these items are not left off.
Standard #:	22VAC40-73-610-B
Complaint related:	No
Description:	Based on observations of the facility physical plant, the facility failed to record meal substitutions on the posted menu. EVIDENCE: 1. The facility posted menu has documentation that the lunch meal on 05/10/2024 is Pot Roast, Swiss Scallop Potatoes and Seasoned Green Beans. The LI observed that Pork Chops, Brussel Sprouts and Cheesy Grits were prepared and served for the lunch meal on 05/10/2024.
Plan of Correction:	Dietary changed lunch and had not had a chance to pull and change menu before the LI removed around 9am. Dietary team were reminded to change menu ASAP when any changes are occurring. 5/11/24