Mayfair House Senior Living — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Mayfair House Senior Living was inspected 12 times between June 28, 2021 and March 17, 2025 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 52 violations under 33 distinct standards. 5 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window and no longer serves any of these on its site. All 12 are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

12/31/2025

Administrator

Tina Botdorf

Licensing inspector

Alyshia E Walker

Inspector phone

(757) 670-0504

Approved for

Residential and Assisted Living Care · Non-Ambulatory

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

March 17, 2025Complaint survey0 violations

Areas reviewed

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: 03/17/2025 from 10:15 am to 1:00 pm. 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 03/13/2025 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: 26 Number of resident records reviewed: 1 Number of staff records reviewed: 0 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(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 4, 2025Complaint survey4 violations

Inspection dates

March 4, 2025 , March 13, 2025 and March 17, 2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 03/04/2025 from 11:05 am to 11:50 am, 03/13/2025 from 11:15 am to 3:25 pm, and 03/17/2025 from 10:15 am to 1:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Four complaints were received by VDSS Division of Licensing on 02/19/2025, 02/20/2025, 03/07/2025, and 03/11/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Background Checks. Number of residents present at the facility at the beginning of the inspection: 26 Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Narcotic medications were counted and documented. Additional Comments/Discussion: All background checks of staff hired from 12/04/2024 (renewal inspection) were reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-640-A

Based on record review and interview, the facility failed to implement their written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes and plan for proper disposal of medication.

Evidence

Resident #2 has an order for Oxycodone 5 mg tab every 8 hours as needed with a maximum daily amount of 15 mg from 12/29/2024-02/04/2025, 02/04/2025-02/17/2025, and up to 14 days starting 02/17/2025. The January, February, and March MAR for Resident #2 indicate it was administered 22 times. Resident #2 was interviewed and indicated they requested the medication specifically on 02/04/2025, 02/05/2025, and 02/06/2025; however, Resident #2 was told by staff it was not available for administration. Staff #3 was unable to provide the narcotic count sheet for the medication (42 tabs) documented as delivered to the facility on 02/04/2025.
Resident #6’s PRN order for Hydrocodone 5-325 mg tab was unable to be located on 03/06/2025. Resident #6 was interviewed and indicates not requesting the medication for administration. The MAR for Resident #6 indicates it was administered once on 03/03/2025. 20 tablets of the medication were delivered to the facility on 02/27/2025 and signed for by Staff #4. Staff #4 indicated the medication included a narcotic count sheet which was placed on the medication cart with the medication upon receipt. In a written statement, Staff #2 indicates they removed the medication from the cart on 03/06/2025 and put in a locked box in the medication room. Staff #5 was interviewed and stated they were working the medication cart on 03/05/2025 when Staff #2 took the medication and narcotic count sheet off the medication cart. Staff #5 believes (based off memory) there were approximately 17 of the 20 tablets within the pack of medication and the packet of medication did not appear to be tampered with or damaged. In a written statement, Staff #1 noticed the medication was not on the medication cart on 03/06/2025. Staff #1 also noted Staff #2 indicated they took the medication and the narcotic count sheet off the cart and into a locked box in the medication room on 03/06/2025. Staff #1 later went to the locked box the medication was in and ?found that the card had been tampered with and was only holding less than maybe 15 pills that had indeed been replaced with Tylenol rather than Hydrocodone.? Upon discovery of this, Staff #1 discarded the pills in the card and the narcotic sheet. The facility was unable to provide or determine where/what occurred to Resident #6’s Hydrocodone tablets.

Plan of correction

All RMA’s have been retrained on company policy and procedures, facility medication management policy and procedures, and proper disposal of medication. All RMAs have retaken the RMA refresher course and have been signed off on medication pass, counts and medication disposal and documentation, by RCD, LPN or Administrator.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

The January 2025, February 2025, and March 2025 MAR indicated Resident #1 did not receive approximately 41 medications during the period reviewed. Additionally, a total of 12 medications were not administered the morning of 1/16/25, a total of 15 medications were not administered the morning of 2/5/25, a total of 15 medications were not administered the morning of 2/15/25, and a total of 11 medications were not administered the morning of 3/1/25 for Resident #1.
The January 2025, February 2025, and March 2025 MAR indicated Resident #2 did not receive approximately 87 medications during the period reviewed. Additionally, Resident #2’s Oxycodone 5 mg tab order indicates it can be administered every 8 hours as needed with a maximum daily amount of 15 mg; however, the narcotic count sheet indicates one dose was administered at 3 pm and then again at 8pm on 02/25/2025 (none documented on MAR), one dose at 8 pm and 9 pm on 03/03/2025 (none documented on MAR), one dose at 6 am and 12 pm on 03/09/2025 (MAR documents 1 administration at 6:28 am), and one dose at 12 am, 4:30 (does not indicate am or pm), and 9 pm on 03/12/2025 (none documented on MAR). Resident #2’s Oxycodone 5 mg tab was noted to still be on the medication cart for administration as of 03/13/2025 despite the order starting 02/17/2025 for up to 14 days (03/03/2025). The MAR documents it was administered 8 times after 03/03/2025. The narcotic count sheet indicates 12 tablets were taken off the medication cart for administration to Resident #2 after 03/03/2025.
The January 2025, February 2025, and March 2025 MAR indicated Resident #3 did not receive approximately 92 medications during the period reviewed. Additionally, a total of 13 medications were not administered on 2/18/25 and a total of 8 medications were not administered the morning of 3/1/25 for Resident #3.
Resident #4’s record indicates Lorazepam .5 mg tab every 6 hours as needed was discontinued 12/17/2025 and restarted 02/26/2025; however, the narcotic count sheet indicates it was taken off the medication cart for administration 12 times in February 2025 (prior to 02/26/2025) and 2 times after 12/17/2025.
Resident #5’s order for Lorazepam .5 mg tab indicates it can be administered every 12 hours as needed; however, the narcotic count sheet indicates a dose of the medication was given at 6pm and 8pm on 02/10/2025. Resident #5’s MAR indicates only 1 dose was administered at 6:15pm on 02/10/2025.

Plan of correction

The RCD, RCC, Administrator or designee will audit all community medication orders for medication availability and non- use. Medications will be ordered/discontinued as appropriate. All medication will be reviewed against valid prescription and physicians order and entered the count as needed. Narcotic counting will be performed using ECP S digital counting feature. The paper counting books has been removed.

22VAC40-73-680-H

Based on record review, the facility failed to ensure at the time the medication is administered, the facility document on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements.

Evidence

The following are days the narcotic count sheet on the medication cart documents staff taking a dose(s) of Oxycodone 5 mg tab off the cart that are not documented as administered on the MAR for Resident #2: 02/18/2025 (2 doses), 02/22/2025 (1 dose), 02/24/2025 (1 dose), 02/25/2025 (3 doses), 02/26/2025 (2 doses), 02/27/2025 (2 doses), 03/01/2025 (1 dose), 03/03/2025 (2 doses), 03/07/2025 (2 doses), 03/08/2025 (2 doses), and 03/09/2025 (1 dose), and 03/12/2025 (3 doses). Additionally, the MAR for Resident #2 indicates 2 doses of the medication were administered on 03/10/2025; however, only 1 tablet was signed off via the narcotic count sheet for administration.
Resident #3 has an order for Tramadol 50 mg tab 2 times daily as needed. The January, February, and March MAR for Resident #3 indicate it has not been administered to Resident #3; however, the narcotic count sheet on the medication cart documents staff taking a dose off the cart each evening from 02/27/2025-03/16/2025 (18 doses). Resident #3 was interviewed and confirmed they receive the medication each evening with scheduled PM medications.
Resident #4 has an order for Lorazepam .5 mg tab every 6 hours as needed starting 02/26/2025. The January, February, and March MAR for Resident #4 indicate it was administered on 02/27/2025, 03/01/2025, 03/03/2025 (2), 03/05/2025, and 03/10/2025; however, the narcotic count sheet on the medication cart documents staff taking a dose(s) off the cart on 02/27/2025, 03/01/2025, 03/03/2025 (2), 03/04/2025, 03/06/2025, 03/08/2025, and 03/09/2025. Four of the doses are not documented on the MAR for Resident #4 as administered. Additionally, the MAR indicates the medication was administered two occasions (03/05/2025 and 03/10/2025) that the medication is not taken off the medication cart via the narcotic count sheets.
Resident #5 has an order for Lorazepam .5 mg tab every 12 hours as needed. The January, February, and March MAR for Resident #5 indicate it was administered on 01/13/2025 and 02/10/2025; however, the narcotic count sheet on the medication cart documents staff taking a dose(s) off the cart on 01/11/2025, 01/13/2025, 01/20/2025 (2), and 02/10/2025 (2). Four of the doses are not documented on the MAR for Resident #5 as administered. Additionally, Resident #5’s MAR indicates only 1 dose was administered at 6:15pm on 02/10/2025 despite two narcotics signed out at 6pm and 8pm.

Plan of correction

All RMA’s have been retrained on company policy and procedures, facility medication management policy and procedures, and completing the medication pass within the required time frame. All RMAs have retaken the RMA refresher course and have been signed off on medication pass, counts and medication disposal and documentation.

22VAC40-90-40-B

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

The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #6 (hired 11/07/2024) did not have a completed report, Staff #7 (hired 10/10/2024) did not have a completed report, Staff #8 (hired 02/15/2025) did not have a completed report, Staff #9 (hired 12/12/2024) completed 3/16/2025, Staff #10 (hired 2/15/2025) completed 3/16/2025, Staff #11 (hired 1/23/2025) completed 3/16/2025, and Staff #12 (hired 2/14/2025) completed 3/16/2025.

Plan of correction

All Criminal Background checks will be completed on or before the first day of employment. The administrator will monitor those that have not been received, daily. Any employee that does not have a criminal background check within 30 days will be terminated.

March 4, 2025Complaint survey1 violation

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 03/04/2025 from 11:05 am to 11:50 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 02/20/2025 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: 26 Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-110-1

Based on record review and interview, the facility failed to ensure staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.

Evidence

On 02/16/2025, Resident #1 provided their card to Staff #3 to purchase personal items for Resident #1.
Staff #1 acknowledged it was determined that Staff #3 utilized Resident #1’s card while in their possession for items/cash for Staff #3.

Plan of correction

All employees have been retrained on company policy for taking money or any kind from residents, families or other staff.

January 24, 2025Inspection3 violations

Inspection dates

Jan. 24, 2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

22VAC40-73-120 22VAC40-73-450

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: 01/24/2025 from 9:45 am to 11:45 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/19/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 27 Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Personnel. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-110-1

Based on record review and interview, the facility failed to ensure staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.

Evidence

On 01/16/2025, Staff #2 was aggressively transferred Resident #1 to bed which resulted in an injury to the resident’s left hand.

Plan of correction

Not published by VDSS.

22VAC40-73-250-C

Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record.

Evidence

Staff #3’s record does not include verification that the staff person has received a copy of their current job description.

Plan of correction

Not published by VDSS.

22VAC40-73-250-D

Evidence

Staff #3 (hired 1/14/2025) did not have a completed TB assessment in their staff record.

Plan of correction

Not published by VDSS.

January 24, 2025Complaint survey4 violations

Inspection dates

Jan. 24, 2025

Areas reviewed

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: 01/24/2025 from 9:45 am to 11:45 am. 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 01/16/2025 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: 27 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-300-B

Based on record review and interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. The information shall be included in the records of the involved residents.

Evidence

Staff #1 confirmed that Resident #1 went to the ER on 01/13/2025; however, there was no documentation of this incident in written communication or in Resident #1’s record.

Plan of correction

Administrator/designee will continue to ensure written/electronic communication is consistently being utilized by all direct care staff on all shifts as a mean of communication.

22VAC40-73-470-F

Based on record review and interview, the facility failed to when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention.

Evidence

Resident #1 went to the ER on 01/13/2025; however, there was no documentation the resident’s physician, next of kin, legal representative, or designated contact person was notified of the situation and action taken.

Plan of correction

All residents who suffer a serious illness or medical condition will be reviewed by the Administrator/designee to ensure that medical attention from a licensed health care professional is secured timely.

22VAC40-73-640-A

Based on record review and interview, the facility failed to implement their written plan for medication management which includes methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.

Evidence

On 01/11/2025, Staff #3 indicated at the start of their shift that there was a discrepancy of 2 narcotics (1 of Resident #1 and 1 of Resident #2) upon counting with Staff #2.
Staff #3 reports there was physically 1 additional capsule of Resident #1’s 100 mg Gabapentin on the medication cart than the number documented on the narcotic count sheet.
Staff #3 also reports there was physically 1 less capsule of Resident #2’s 300 mg Gabapentin on the medication cart than the number documented on the narcotic count sheet.
Staff #3 indicated these discrepancies were verbally reported to Staff #4.
The narcotic count sheet for Resident #2’s 300 mg Gabapentin capsule captured a discrepancy on 01/11/2025. It indicates there were 3 remaining capsules on 01/09/2025 and 1 remaining on 01/11/2025. Resident #2 was in the hospital the evening of 01/10/2025 and there is no documentation to show what happened to missing dose.
There was no evidence a medication aide note was made nor if there was a need of medication disposal despite the facility’s medication management plan policy and procedure to account for the discrepancies noted on 01/11/2025.

Plan of correction

Facility will continue to follow the medication management plan. Administrator/designee will work with the Medication Technicians and review the med. management plan as well as the importance of medications being administered in accordance with physician's orders.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

Resident #1 has an order for Midodrine 10 mg tablet to be administered every 6 hours with a parameter to be held if SBP is greater than 130; however, the MAR indicates the medication was held on 5 occasions (3 doses on 1/1/2025 and 2 doses on 1/2/2025) despite their SBP being less than 130.
The January 2025 MAR indicated Resident #1 did not receive the following medications on the following days: Docusate 100 mg capsule on 1/5/2025, Eliquis 2.5 mg tab on 1/5/2025-1/12/2025, Fluticasone spray 1/1/2025- 1/12/2025, Lexapro 5 mg tab on 1/7/2025, Midodrine 10 mg tab on 1/6/2025, and Zinc 30 mg tab on 1/6/2025-1/8/2025 and 1/10/2025-1/12/2025.

Plan of correction

Medications will be administered in accordance with the physician's or other prescribers? instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

December 20, 2024Complaint survey3 violations

Inspection dates

Dec. 20, 2024 and Jan. 2, 2025

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

Technical assistance

22VAC40-73-650

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: 12/20/2024 from 10:10 am to 11:40 am and 01/02/2025 from 11:15 am to 11:35 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two complaints were received by VDSS Division of Licensing on 12/17/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 26 Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: The food supply was reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-680-C

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

The December 2024 MAR for Resident #1 indicates Resident #1 did not receive the following medications on the following days: 1 dose of Methocarbamol on 12/6/24, 12/7/24, 12/14/24, and 12/15/24, Duloxetine on 12/12/24, 1 dose of Eliquis on 12/7/24, 12/14/24, and 12/15/24, Gabapentin on 12/2/24, 12/3/24, 12/6/24, 12/7/24, 12/9/2024- 12/12/2024, and 12/24/2024-12/26/2024, Pramipexole on 12/14/24 and 12/15/24, and Verapamil on 12/14/24 and 12/15/24.

Plan of correction

Medication times are currently being reviewed and appropriately adjusted to assure that each medication pass can be appropriately managed per regulatory standard of an hour before/after. RCD or designee will complete regular, random audits of medication pass to ensure medications are being passed within regulatory standards.

22VAC40-73-680-D

Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

Resident #1 physically admitted to the facility on 10/25/2024 from a skilled nursing facility.
The following medications were ordered upon discharge from the SNF and were not documented on the resident’s MAR for administration: Miralax 17gm daily, Voltaren gel, Tylenol 500mg QID, and Iron 325mg daily.
The resident’s record did not include a discontinued orders for the medications listed during the onsite inspection.

Plan of correction

Medication audits will be completed on all medication administration records to ensure all medications are given as prescribed by physician’s orders. RCD or designee will re-educate staff of medication management policy. RCD/RCC will ensure residents? orders will be sent to the facility and faxed to current MD.

22VAC40-73-870-A

Based on observation, the facility failed to ensure the interior and exterior of the building be maintained in good repair and kept clean and free of rubbish.

Evidence

The toilet in the bathroom of Resident #2 and Resident #3 was noted to move upon the touch as it was not bolted to the floor.

Plan of correction

Area identified with unbolted toilet will be repaired and/or replaced if beyond repair. Maintenance will monitor physical plant ongoing to address any further related issues.

December 4, 2024Inspection8 violations

Inspection dates

Dec. 4, 2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical assistance

22VAC40-73-450 22VAC40-73-490 22VAC40-73-530

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: 12/04/2024 from 8:45 am to 3:15 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: 27 Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 2 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

22VAC40-73-440-A

Based on record review, the facility failed to complete a resident’s UAI whenever there is a significant change in a resident’s condition.

Evidence

Resident #2 admitted to hospice in September 2024; however, the UAI in the record of Resident #2 was completed on 07/18/2024.

Plan of correction

Nurse will review and update all residents Care Plans to ensure all dates, ALDs and Hospice services are included.

22VAC40-73-450-C

Based on record review, the facility failed to ensure the comprehensive individualized service plan should include a description of identified needs and date identified based upon the UAI.

Evidence

Resident #2’s UAI (dated 07/18/2024) indicates Resident #2 requires assistance with toileting, transferring, bowel incontinence, wheeling, stairclimbing, money management, and medication administration; however, Resident #2’s ISP (dated 11/03/2024) does not address these needs.

Plan of correction

ISP was corrected on 12/05/2024. Residents UAI and Care Plan were revised to match. Nurse will review all care plans and update if needed.

22VAC40-73-680-C

Evidence

During a medication observation on 12/04/2024, Resident #1 was administered their scheduled 8:00 am medications (7 total) at approximately 9:30 am. Additionally, Fluticasone 50mcg spray was not available for administration.
The November 2024 MAR for Resident #2 indicates Resident #2 did not receive the following number of scheduled medications on the following day: 8 on 11/12/2024, 4 on 11/13/2024, 1 on 11/16/2024, 3 on 11/20/2204, and 1 on 11/25/2024.
The November 2024 MAR for Resident #3 indicates Resident #3 was not administered Tramadol from 11/09/2024- 11/14/2024 as the medication was not available.
The November 2024 MAR for Resident #4 indicates Resident #4 was not administered 3 scheduled medications on 11/13/2024. The November 2024 MAR for Resident #4 indicates Resident #4 was also not administered Omeprazole on 11/20/2024 and 11/21/2024.

Plan of correction

Nurse/RCC will review and adjust administration times for medications as needed. All RMA’s will be retrained to ensure all prescribed medications are in the building and given within the required times.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

Resident #1 has an order for Famotidine 20 mg tablet to be administered once daily with lunch; however, the medication is scheduled on the MAR and administered for/at 8:00 am.
Resident #1 has an order for Midodrine 10 mg tablet to be administered every 6 hours with a parameter to be held if SBP is greater than 130; however, the MAR indicates the medication was held on 9 times in November (3 doses on 11/27/2024 1 dose on 11/28/2024 3 doses on 11/29/2024 and 2 doses on 11/30/2024) despite Resident #1’s SBP on 11/27/2024, 1 dose on 11/28/2024, 3 doses on 11/29/2024, and 2 doses on 11/30/2024) despite Resident #1’s SBP on those occasions being less than 130.

Plan of correction

Not published by VDSS.

22VAC40-73-950-F

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

The facility could not provide documentation of an annual review of the emergency preparedness and response plan.

Plan of correction

The Emergency Plan was reviewed and signed by VPO and Administrator during survey. Plan reviewed and signed by all staff.

22VAC40-73-970-E

Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills include the items identified in the standard.

Evidence

The record of the required fire and emergency evacuation drills from May 2024 to current did not include all the items identified in the standard.

Plan of correction

Fire Drills will be recorded on state model form.

22VAC40-90-30-B

Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment.

Evidence

Staff #9 and Staff #10 did not have a completed sworn disclosure in their record.

Plan of correction

The Administrator will ensure all new hires complete a sworn affirmation statement prior to their hire date. All staff files have been audited to ensure compliance.

22VAC40-90-40-B

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

The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #6 (hired 10/10/2024) completed 11/27/2024, Staff #7 (hired 06/08/2024) completed 11/29/2024, Staff #8 (hired 09/20/2024) completed 11/25/2024, Staff #10 (hired 10/15/2024) did not have a completed report at the time of the inspection, and Staff #11 (hired 10/10/2024) did not have a completed report at the time of the inspection.

Plan of correction

The Administrator will audit all employee files to ensure the facility is compliant with criminal background checks standard. Background checks that do not arrive by the 30th day of employment, will result in immediate employee termination.

December 12, 2023Inspection15 violations

Inspection dates

Dec. 12, 2023

Areas reviewed

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

22VAC40-73-210-B

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

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.

22VAC40-73-290-B

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

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.

22VAC40-73-325-A

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

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.

22VAC40-73-325-B

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

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.
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.

22VAC40-73-330-A

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

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.

22VAC40-73-610-E

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

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.

22VAC40-73-680-C

Evidence

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.
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.
Resident #4’s 8 am (6 medications) medications were not documented on the MAR as administered on 12/7/2023.
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.

22VAC40-73-680-I

Based on record review and interview, the facility failed to ensure the MAR include the dosage administered.

Evidence

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.
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.

22VAC40-73-870-A

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

During a tour of the facility, a stackable washer and dryer unit was noted on an entrance to a resident occupied hallway.
Two closet doors in Resident #6’s apartment was noted to be leaning against the rack within the closet.
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.
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 good epa a d es de t c oset doo s a e o t ac .

22VAC40-73-950-F

Evidence

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.

22VAC40-73-970-A

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

There was no documentation of a fire and emergency evacuation drill conducted from 4/25/2023-8/9/2023.

Plan of correction

Not published by VDSS.

22VAC40-73-980-C

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

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 published by VDSS.

22VAC40-73-990-C

Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.

Evidence

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.

22VAC40-90-30-B

Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment.

Evidence

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.

22VAC40-90-40-B

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

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.

October 25, 2022Inspection3 violations

Inspection dates

Oct. 25, 2022

Areas reviewed

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

22VAC40-73-260-A

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

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.

22VAC40-73-325-B

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

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.
Upon review of the resident’s record, the last annual fall risk rating for the Resident #2 was completed 02/27/2021.
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.
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.
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.

22VAC40-73-680-I

Based on record review and interview, the facility failed to ensure the MAR include all medications prescribed to a resident.

Evidence

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.
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.

January 25, 2022Inspection4 violations

Inspection dates

Jan. 25, 2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

Blood glucose orders and orders for insulin administration are to include parameters on when to notify the physician.

Comments

A renewal inspection was initiated 01/25/2022 and concluded on 01/27/2022. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 15. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, two staff records, fire drills, criminal history reports, fire drills, activities calendar menu and staff schedules, submitted by the facility to ensure documentation was complete. The inspector conducted a virtual inspection with the administrator on 01/27/2022. An exit interview was conducted with 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.

Violations

22VAC40-73-440-D

Based on review of residents? records, the facility failed to ensure the Uniform Assessment Instrument (UAI) is completed as required by 22 VAC 30-110.

Evidence

The medication administration section on the Uniform Assessment Instrument (UAI) for resident 2, dated 06/16/2021 is not completed.

Plan of correction

UAI will be reviewed by Administrator/LPN after completion for accuracy.

22VAC40-73-450-C

Based on review of residents? records, the facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP).

Evidence

The UAI for resident 2, dated 06/216/2021 indicates resident requires mechanical and physical assistance with dressing. The ISP dated 06/16/2021 indicates physical assistance only.
The January dietary sheet and the January Medication Administration Record (MAR) for resident 2 indicate resident has a diet of Nectar Thickened Liquids. The ISP dated 06/16/2021 indicates regular diet.

Plan of correction

ISP/UAI will be reviewed by Administrator/LPN after completion for accuracy of all care needs.

22VAC40-73-680-D

Based on review of residents? records, the facility failed to ensure medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Resident 1 has the following order: Sliding Scale Insulin three times daily before meals for DMII-150-199 2U; 200-249 3U; 250-299 5U; 300-349 7U; 350-399 8U; 400-449 10U.
The January Blood Glucose log for resident 1 indicates on 01/09/2022 at 4:30pm resident’s blood glucose reading is
The MAR indicates 2 units were administered; however resident should not have received any insulin.
The January Blood Glucose log for resident 1 indicates on 01/15/2022 at 4:30pm resident’s blood glucose reading is
The MAR indicates 2 units were administered; however resident should have received 3 units.
The January Blood Glucose log for resident 1 indicates on 01/18/2022 at 7:30am resident’s blood glucose reading is
The MAR indicates 2 units were administered; however resident should have received 3 units.
The January Blood Glucose log for resident 1 indicates on 01/19/2022 at 4:30pm resident’s blood glucose reading is
The MAR indicates insulin was not administered; the resident should have received 2 units. 6.The January Blood Glucose log for resident 1 indicates on 01/22/2022 at 7:00am resident’s blood glucose reading is
The MAR indicates insulin was not administered; the resident should have received 2 units.
The January Blood Glucose log for resident 1 indicates on 01/23/2022 at 7:00am resident’s blood glucose reading is
The MAR indicates insulin was not administered; the resident should have received 2 units.

Plan of correction

Electronic Mars were implemented in facility to assist with more accuracy with documentation. Pharmacy oversite conducted by ACT pharmacy for review and discussion concerning documentation and accuracy. In-service presented to Medication Aides by Pharmacy for review on Sliding Scale and hyperglycemia to assist with understanding concerning residents on insulin. Medication Aides will do "buddy checks" with each other, RCC/LPN for accuracy prior to administration of insulin. Physician Orders will include parameters notification of physician with insulin and glucose monitoring.

22VAC40-73-700-1

Based on review of residents? records, the facility failed to ensure oxygen orders include all required components.

Evidence

The oxygen order for resident 3, dated 11/11/2021 does not include the delivery device or oxygen source.

Plan of correction

Orders will be reviewed for accuracy including oxygen source and delivery service. Hospice providers will review instructions to include all necessary information. Orders will be reviewed by LPN/RCC.

November 12, 2021Inspection4 violations

Inspection dates

Nov. 12, 2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 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

22VAC40-73-250-D

Evidence

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.

22VAC40-73-530-B

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

On 11-30-2021, upon entering the facility, the front door of the facility requires a code to enter and exit the building.
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.

22VAC40-73-660-B

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

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.
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.

22VAC40-90-40-B

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

Staff #3 provided a list of newly hired staff and dates of hire to include Staff #4 (date of hire on 10-01-2021).
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.”
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.

June 28, 2021Inspection3 violations

Areas reviewed

22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation

Comments

An initial inspection was initiated on 06-28-2021 and concluded on 06-28-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 18. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed criminal background checks submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 06-28-2021. 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 with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-870-A

Based on observation and interview, the facility failed to ensure the interior of the building was kept in good repair.

Evidence

During the facility tour with staff #1, staff #2, and staff #3, the following areas observed were not in good repair: A. The vaulted ceiling in the dining room had an octagon shaped opening that was discolored with black spots and markings that surrounded the area of the opening; B. The ceiling located near the kitchen in the dining room was discolored and had a crack that was approximately 12? in length; C. The ceiling tile located in the bathroom of room #407 had a brown circular stain that was approximately the size of a baseball; and D. Three ceiling tiles located in room #417 were discolored. One of the tiles had brown spots approximately 7? in length, and the other tile had a brown circular stain that was approximately the size of a baseball.
Staff #1, staff #2, and staff #3 acknowledged aforementioned areas were not in good repair.

Plan of correction

A. Vaulted ceiling will be cleaned, primed, and painted B. Ceiling area with crack will be repaired and painted. C & D. Ceiling tiled will be replaced or painted.

22VAC40-73-920-C

Based on observation and interview, the facility failed to ensure that all bathrooms had ventilation to the outside in order to eliminate foul odors.

Evidence

During the facility tour with staff #1, staff #2, and staff #3, the bathroom vent in room #205 was observed inoperable. When the switch was placed in the on position, the fan did not come on. In addition, the bathroom in room #210 did not have a ventilation system.
Staff #1, staff #2, and staff #3 acknowledged aforementioned bathrooms did not ventilate to the outside. ill b ill itt d t til

Plan of correction

Contractor will be engaged to install fans in bathrooms. Residents will not be admitted to these rooms until complete.

22VAC40-73-960-B

Based on observation and interview, the facility failed to ensure the posted fire and emergency evacuation drawing showed the assembly areas.

Evidence

During the facility tour with staff #1, staff #2, and staff #3 the posted fire and emergency evacuation drawings observed near rooms #405, #102, #415, #427, and #202 did not include the assemble areas.
Staff #1, staff #2, and staff #3 acknowledged the posted fire and emergency evacuation drawings did not include the assemble areas.

Plan of correction

All posted fire and emergency evacuation drawings will have assembly area indicated on drawings.