1 Inspection Summary
Inspection Reports Summary
Covers 12 inspections · Jun 2021 – Mar 2025Visit Reason
This report covers 12 inspections of Mayfair House Senior Living from June 28, 2021 to March 17, 2025, including complaint and routine inspections.
Complaint Details
Five inspections were complaint surveys prompted by allegations in Resident Care and Related Services and Background Checks. Investigations included interviews, record reviews, and observations. Some complaints were supported with violations issued; others found no violations.
Findings
Across that history VDSS cited 52 violations under 33 distinct standards. Five inspections were prompted by a complaint.
Violations (54)
22VAC40-73-640-A: Failed to implement medication management plan ensuring accurate narcotic counts and disposal.
22VAC40-73-680-D: Medications not administered per physician's or prescriber's instructions.
22VAC40-73-680-H: MAR did not document all medications administered including OTC and supplements.
22VAC40-90-40-B: Failed to obtain criminal history record report on or before 30th day of employment for some staff.
22VAC40-73-110-1: Staff not considerate and respectful of rights and dignity of aged or disabled persons.
22VAC40-73-110-1: Staff not considerate and respectful of rights and dignity of aged or disabled persons.
22VAC40-73-250-C: Staff record missing personal and social data.
22VAC40-73-250-D: Staff record missing completed TB assessment.
22VAC40-73-300-B: Failed to use written communication to keep direct care staff informed of significant resident issues.
22VAC40-73-470-F: Failed to notify physician, next of kin, or responsible parties timely after serious resident incident.
22VAC40-73-640-A: Failed to implement medication management plan ensuring accurate narcotic counts.
22VAC40-73-680-D: Medications not administered per physician's or prescriber's instructions.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled time.
22VAC40-73-680-D: Medications not administered per physician's or prescriber's instructions.
22VAC40-73-870-A: Interior and exterior of building not maintained in good repair and clean.
22VAC40-73-440-A: Failed to complete UAI after significant change in resident condition.
22VAC40-73-450-C: ISP did not include description of identified needs based on UAI.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled time.
22VAC40-73-680-D: Medications not administered per physician's or prescriber's instructions.
22VAC40-73-950-F: Failed to review emergency preparedness plan annually and document review.
22VAC40-73-970-E: Fire and emergency evacuation drill records incomplete.
22VAC40-90-30-B: Failed to complete sworn statement or affirmation for all employment applicants.
22VAC40-90-40-B: Failed to obtain criminal history record report on or before 30th day of employment for some staff.
22VAC40-73-210-B: Direct care staff failed to attend required annual training hours.
22VAC40-73-290-B: Failed to post name of current on-site person in charge conspicuously.
22VAC40-73-325-A: Failed to complete fall risk rating for residents meeting assisted living criteria.
22VAC40-73-325-B: Failed to complete fall risk rating annually, after condition changes, or after falls.
22VAC40-73-330-A: Failed to conduct mental health screening prior to admission when indicated.
22VAC40-73-610-E: Diet manual not current or readily available to food preparation personnel.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled time.
22VAC40-73-680-I: MAR did not include dosage administered.
22VAC40-73-870-A: Interior of building not maintained in good repair and clean.
22VAC40-73-950-F: Failed to review emergency preparedness plan annually and document review.
22VAC40-73-970-A: Fire and emergency evacuation drills not conducted per code frequency and participation.
22VAC40-73-980-C: Failed to check first aid kits monthly for completeness and expiration.
22VAC40-73-990-C: Failed to document staff participation in resident emergency practice exercises every six months.
22VAC40-90-30-B: Failed to complete sworn statement or affirmation for all employment applicants.
22VAC40-90-40-B: Failed to obtain criminal history record report on or before 30th day of employment for some staff.
22VAC40-73-260-A: Direct care staff failed to maintain current first aid certification from approved sources.
22VAC40-73-325-B: Failed to complete fall risk rating annually, after condition changes, or after falls.
22VAC40-73-680-I: MAR did not include all prescribed medications for resident.
22VAC40-73-870-A: Interior of building not maintained in good repair and clean.
22VAC40-90-40-B: Failed to obtain criminal history record report on or before 30th day of employment for some staff.
22VAC40-73-440-D: Failed to complete Uniform Assessment Instrument as required.
22VAC40-73-450-C: ISP did not include assessed needs of resident.
22VAC40-73-680-D: Medications not administered per physician's or prescriber's instructions.
22VAC40-73-700-1: Oxygen orders missing required components.
22VAC40-73-250-D: TB screening completed after hire date.
22VAC40-73-530-B: Doors leading outside locked requiring code, restricting free exit.
22VAC40-73-660-B: Resident permitted to keep medication in room despite inability to self-administer.
22VAC40-90-40-B: Failed to obtain criminal history record report on or before 30th day of employment for some staff.
22VAC40-73-870-A: Interior of building not kept in good repair with ceiling and ventilation issues.
22VAC40-73-920-C: Bathrooms lacked ventilation to outside to eliminate odors.
22VAC40-73-960-B: Posted fire and emergency evacuation drawings lacked assembly areas.
Report Facts
Violations cited: 52
Distinct standards: 33
Inspections on page: 12
Inspections with violations: 11
Complaint visits: 5
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