Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Mar 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-13 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
Complaint related inspection triggered by allegations in Resident Care and Related Services; the complaint was not substantiated.
Report Facts
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
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Mar 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a self-reported incident received on 2025-02-20 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance related to staff failing to be considerate and respectful of the rights, dignity, and sensitivities of residents. A violation was issued based on record review and interviews indicating misuse of a resident's card by staff.
Complaint Details
The complaint was substantiated based on evidence that Staff #3 utilized Resident #1's card for personal items/cash while in possession of the card.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. |
Report Facts
Number of residents present: 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
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 4
Mar 4, 2025
Visit Reason
The inspection was conducted in response to four complaints received by VDSS Division of Licensing regarding Resident Care and Related Services and Background Checks.
Findings
The investigation found multiple violations related to medication management, including failure to implement accurate narcotic counts, improper medication administration, incomplete documentation on medication administration records, and failure to obtain timely criminal history record reports for staff.
Complaint Details
Four complaints were received on 02/19/2025, 02/20/2025, 03/07/2025, and 03/11/2025 regarding Resident Care and Related Services and Background Checks. The evidence gathered supported the allegations of non-compliance and violations were issued.
Deficiencies (4)
| Description |
|---|
| Facility failed to implement their written plan for medication management including accurate counts of controlled substances and proper disposal of medication. |
| Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions. |
| Facility failed to document all medications administered to residents on the medication administration record (MAR), including over-the-counter medications and dietary supplements. |
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for several employees. |
Report Facts
Residents present: 26
Resident records reviewed: 6
Staff records reviewed: 0
Resident interviews conducted: 5
Staff interviews conducted: 5
Medications not administered to Resident #1: 41
Medications not administered to Resident #2: 87
Medications not administered to Resident #3: 92
Staff without timely criminal history report: 3
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Jan 24, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-16 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards and violations were issued related to communication failures, securing timely medical attention, medication management discrepancies, and failure to administer medications according to physician orders.
Complaint Details
The complaint investigation substantiated violations related to resident care, including failure to document incidents, failure to notify physicians and next of kin, medication discrepancies, and improper medication administration.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a method of written communication was utilized to keep direct care staff informed of significant resident issues, including complaints and incidents. |
| Facility failed to secure medical attention immediately and notify appropriate parties when a resident suffered a serious accident or illness. |
| Facility failed to implement their written medication management plan ensuring accurate counts of controlled substances during staff changes. |
| Facility failed to administer medications in accordance with physician or prescriber instructions. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of staff interviews conducted: 4
Medication discrepancies: 2
Medication doses held incorrectly: 5
Inspection Report
Monitoring
Census: 27
Deficiencies: 3
Jan 24, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 01/19/2025 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the self-report; non-compliance was found in the area of Personnel. A violation notice was issued with deficiencies related to staff conduct, staff records, and tuberculosis screening documentation.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled; Staff #2 aggressively transferred Resident #1 resulting in injury. |
| Facility failed to ensure personal and social data are maintained on staff and included in the staff record; Staff #3's record lacked verification of receipt of current job description. |
| Facility failed to ensure each staff person submits results of a tuberculosis risk assessment prior to contact with residents; Staff #3 did not have a completed TB assessment. |
Report Facts
Number of residents present: 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
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Dec 20, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing on 12/17/2024 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported the allegations of non-compliance with standards related to medication administration timing, adherence to physician's medication orders, and maintenance of the facility's interior and exterior. Violations were issued based on these findings.
Complaint Details
Two complaints were received on 12/17/2024 regarding Resident Care and Related Services and Buildings and Grounds. The evidence gathered supported the allegations, and violations were issued.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure the interior and exterior of the building were maintained in good repair and kept clean and free of rubbish; specifically, a toilet in the bathroom of two residents was not bolted to the floor. |
Report Facts
Residents present: 26
Resident records reviewed: 4
Staff records reviewed: 0
Resident interviews conducted: 4
Staff interviews conducted: 4
Inspection Report
Renewal
Census: 27
Deficiencies: 8
Dec 4, 2024
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection found multiple violations including failure to complete resident UAIs after significant condition changes, incomplete individualized service plans, medication administration errors, failure to review emergency preparedness plans annually, incomplete fire drill records, and deficiencies in employee background check documentation.
Deficiencies (8)
| Description |
|---|
| Failed to complete a resident's UAI whenever there is a significant change in a resident's condition. |
| Failed to ensure the comprehensive individualized service plan includes a description of identified needs and date based upon the UAI. |
| Failed to ensure medications are administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. |
| Failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions. |
| Failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan. |
| Failed to ensure a record of the required fire and emergency evacuation drills include all required items. |
| Failed to ensure a sworn statement or affirmation be completed for all applicants for employment. |
| Failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 3
Medication administration errors: 8
Medication administration errors: 4
Medication administration errors: 1
Medication administration errors: 3
Medication administration errors: 1
Medication doses held: 9
Staff missing sworn statements: 2
Staff missing criminal history reports: 2
Inspection Report
Monitoring
Census: 37
Deficiencies: 15
Dec 12, 2023
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at Mayfair House Senior Living.
Findings
The inspection identified multiple violations including failure to ensure required staff training hours, lack of posting of the current on-site person in charge, incomplete fall risk ratings for residents, missing mental health screenings, medication administration documentation errors, building maintenance issues, emergency preparedness plan deficiencies, and incomplete employee background checks.
Deficiencies (15)
| Description |
|---|
| Failed to ensure all direct care staff attend required annual training hours. |
| Failed to post the name of the current on-site person in charge in a conspicuous place. |
| Failed to complete written fall risk ratings for residents meeting assisted living care criteria. |
| Failed to complete fall risk ratings annually, after condition changes, and after falls. |
| Failed to conduct mental health screening prior to admission for residents with recent concerning behaviors. |
| Failed to keep a current diet manual readily available to food preparation personnel. |
| Failed to ensure medications were administered within the facility's standard dosing schedule and properly documented. |
| Failed to include dosage administered on the Medication Administration Record (MAR). |
| Failed to maintain the interior of the building in good repair and free of rubbish. |
| Failed to review and document annual review of the emergency preparedness plan. |
| Failed to conduct fire and emergency evacuation drills as required by state code. |
| Failed to ensure monthly checks of first aid kits were documented. |
| Failed to document staff participation in resident emergency practice exercises at least every six months. |
| Failed to ensure sworn statements or affirmations were completed for all employment applicants. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for multiple staff. |
Report Facts
Number of residents present: 37
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of interviews with residents: 3
Number of interviews with staff: 3
Number of medications not documented as administered: 6
Number of medications not documented as administered: 5
Number of medications not documented as administered: 2
Number of medications not documented as administered: 12
Inspection Report
Renewal
Census: 11
Deficiencies: 3
Oct 25, 2022
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with several standards including staff certification in first aid, completion of fall risk ratings, and medication administration records. Violations were documented and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid from an approved source. |
| Facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. |
| Facility failed to ensure the Medication Administration Record (MAR) includes all medications prescribed to a resident. |
Report Facts
Number of residents present: 11
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Inspection Report
Renewal
Census: 15
Deficiencies: 4
Jan 25, 2022
Visit Reason
A renewal inspection was initiated on 01/25/2022 and concluded on 01/27/2022 to review compliance with regulatory requirements for Mayfair House Senior Living.
Findings
The inspection identified multiple deficiencies including incomplete Uniform Assessment Instrument documentation, discrepancies between assessed resident needs and Individualized Service Plans, medication administration errors related to insulin dosing, and incomplete oxygen orders.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Uniform Assessment Instrument (UAI) is completed as required. |
| Facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP). |
| Facility failed to ensure medications are administered in accordance with physician's instructions, specifically insulin dosing errors. |
| Facility failed to ensure oxygen orders include all required components. |
Report Facts
Resident census: 15
Insulin dosing errors: 7
Inspection Report
Monitoring
Census: 17
Deficiencies: 4
Nov 12, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws, including a remote documentation review and an on-site inspection.
Findings
The inspection identified multiple violations including failure to complete tuberculosis screenings prior to hire, improper locking mechanisms on facility doors, failure to allow residents to keep medication in their rooms when capable, and incomplete criminal history record reports for employees.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure tuberculosis screenings were completed prior to hire for staff. |
| Facility failed to ensure doors leading outside were unlocked or secured in a manner that does not amount to a lock. |
| Facility failed to allow a resident capable of self-administering medication to keep medication in an out-of-sight place in their room. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for employees. |
Report Facts
Census: 17
Staff hire date: Nov 9, 2021
Staff hire date: Oct 1, 2021
Criminal record report request date: Oct 18, 2021
Criminal record report status date: Nov 17, 2021
Inspection Report
Original Licensing
Census: 18
Deficiencies: 3
Jun 28, 2021
Visit Reason
An initial inspection was conducted to review compliance with applicable standards and laws for Mayfair House Senior Living.
Findings
The inspection identified multiple violations including poor building maintenance with damaged ceilings, lack of bathroom ventilation, and incomplete fire and emergency evacuation drawings.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the interior of the building was kept in good repair, including discolored and damaged ceilings in multiple rooms. |
| Facility failed to ensure that all bathrooms had ventilation to the outside to eliminate foul odors; some bathroom vents were inoperable or missing. |
| Facility failed to ensure the posted fire and emergency evacuation drawings showed the assembly areas. |
Report Facts
Number of residents present: 18
Length of ceiling crack: 12
Size of ceiling stains: 7
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