The Mayflower on Main Assisted Living
Families consistently rate this highly — reviewers highlight compassionate and professional staff. Schedule a visit to confirm the fit.
based on 9 Google reviews
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What this means for your family
The Mayflower on Main offers a highly rated, compassionate environment with a staff that treats residents like family. Since reviews consistently highlight the quality of care and engaging activities, you can feel confident in their ability to support your loved one's independence.
Google Reviews
Google Reviews
9 reviews on Google“Families can expect a warm, inviting atmosphere where staff members are consistently praised for being professional, friendly, and genuinely caring. Reviewers highlight the smooth transition process and the facility's ability to provide a safe, engaging environment with delicious meals and fun activities.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and professional staff
- Smooth transition and admission process
- Engaging activities and social environment
- Clean and inviting historical atmosphere
Rating Trends
Tap a year to see what changed
Distribution · 9 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1We love the historical atmosphere of the building; how do you maintain that classic charm while ensuring the facility stays modern and easy to navigate for seniors?
- 2The transition process seems very smooth based on what we've heard; what are the first steps we should take to help our loved one settle in comfortably?
- 3We are looking for a lively environment; could you tell us more about the specific social activities and group outings planned for the residents each week?
- 4With a smaller, intimate community of 39 residents, how does the staff ensure that everyone's individual care needs and medical changes are monitored closely?
- 5How does the team handle medical emergencies or urgent care needs during the overnight hours?
- 6It is wonderful to see such high praise for the compassion of your staff; how do you foster that culture of kindness during the daily care routines?
Personalized based on this facility's data
Key Review Excerpts
“Transitioning our loved one to the Mayflower was a smooth process.The staff is incredibly friendly and accomadating.Everyone we have highly met and interacted with has been polite,professional, and they genuinely care for the residents.”
“The Mayflower gives them back their independence to thrive by giving them the support they need with daily living tasks.”
“What a wonderful, compassionate community for seniors! The Mayflower is a home away from home! The activities keep the residents engaged and the meals are quit delicious!”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Oct 22, 2025Routine
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: 10/22/2025 9:00am until 10:33am 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 10/10/2025 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: 16 Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on resident record review, facility documentation and staff interviews, the facility failed to implement their medication management plan (MMP) in regard to the facility?s standard operating procedures. EVIDENCE: 1. On 10/22/2025, the day of on-site inspection the facility MMP that was made available for review has documentation on page 2 that ? To assure administration accuracy the Licensed Nurse or the Registered Medication Aide will check, for each medication administered, the following: Right resident, Right medication, Right does, Right route, Right time, as well as the Right documentation.? 2. A self-reported incident received by the licensing inspector (LI) on 10/10/2025 has documentation that when passing medication to resident 1, staff persons 1 and 2 pulled medication from resident 2?s supply and administered to resident 1. 3. The record for resident 1 has documentation of a physician order dated 08/26/2025 for Morphine Sulf 0.25ml (5mg) by mouth/under tongue every hour as needed. On 10/06/2025 a physician order was noted that changed the Morphine Sol to 0.5ml (10mg) PO every hour as needed. On 10/07/2025 a physician order was noted for Morphine 0.5ml (10mg) scheduled every 4 hours. In an interview with staff person 3 conducted on 10/22/2025, staff person 3 explained that the 08/26/2025 Morphine order was sent from the pharmacy in exact dose syringes and 1 syringe contained the 0.25ml (5mg) Morphine dose. When the order changed on 10/06/2025 to Morphine 0.5ml (10mg) the pharmacy again sent syringes that contained the exact 0.5ml (10mg) dose. Staff person 3 explained that resident 1?s Hospice had instructed the facility to use the remaining supply of Morphine 0.25ml (5mg) syringes and to 2 give syringes at a time to equal the new dose of Morphine 0.5ml (10mg). 4. Documentation on a Controlled Drug Record for resident 1 has documentation that on 10/08/2025 Morphine 0.25ml (5mg), 2 syringes to equal 0.5ml (10mg) were administered to resident 1 six times (12 syringes in total). In an interview conducted on 10/22/2025 with staff person 3, staff person 3 explained that when resident 1?s 0.25ml (5mg) Morphine syringes were completed, instead of using resident 1?s 0.5ml (10mg) syringes, staff persons 1 and 2 had pulled the syringes from resident 2?s Morphine supply who had a physician order for Morphine Sul 0.25ml (5mg) every hour as needed. Resident 2?s Morphine had also been sent from the pharmacy in exact dose syringes and 1 syringe contained the 0.25ml (5mg) Morphine dose.
Oct 22, 2025Routine
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: 10/22/2025 9:00am until 1:30pm 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on observation of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. At approximately 9:54am on the day of on-site inspection, the licensing inspector, in the presence of staff person 2, observed the door to the staff bathroom located by the stairs of the main lobby of the facility was open. A bottle of Monogram Toilet Bowl Cleaner was observed sitting in the unlocked cabinet under the sink and a container of Clorox Disinfectant Wipes was observed sitting in the unlocked cabinet beside the toilet.
Based on observations of the facility physical plant, the facility failed to ensure that the interior of the building was kept clean. EVIDENCE: 1. At approximately 9:58am on the day of on-site inspection, the licensing inspector, in the presence of staff persons 1 and 2, observed that the carpet on the first floor in the main lobby, down the hallways and on the stairs had numerous stains/discolored areas.
Dec 3, 2024Routine
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: 12/03/2024 11:00am until 2:00pm 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: 13 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The record for resident 1 has documentation of a physician order dated 11/25/2024 for Nitrofurantoin Monohyd Macro 100 MG capsule, 1 capsule with food orally every 12 hours for 7 days, which totals 14 doses to be administered. 2. The November 2024 medication administration record ( MAR
Based on observation of the facility physical plant, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. At 11:46am on the day of on-site inspection, the LI, in the presence of staff person 1 and 2, observed that the closet next to the beauty shop was unlocked and contained several bottles of Gonzo Disinfectant Deodorizer & Cleaner, a bottle of Bioesque Botanical Disinfectant Solution and several bottles of Ready 50% Rubbing Alcohol.
Dec 3, 2024Routine
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: 12/03/2024 11:00am until 2:00pm 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: 13 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 Additional Comments/Discussion: During the on-site inspection the LI discussed with the facility Administrator and Corporate that if any additional recommendations have been made by the Engineer to please send them to the LI for review. The LI also requested that any inspections completed by the local Building Official for current construction permits be provided to the LI for review. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on observations made during an on-site inspection conducted on 12/03/2024, the facility failed to maintain the interior and exterior of the building in good repair and free of rubbish. EVIDENCE: The following was observed in the presence of the licensing inspector and staff person 1 and 2 on the day of inspection: 1. The awning over the front porch was noted to have paint/wood damage to the left side of the awning. 2. A hole was noted in the ceiling of the front porch near the second column to the right side of the porch. 3. The kitchen floor was noted to have several missing tiles in front of the utility cabinet near the refrigerator. 4. The support beams in the parking garage were noted to have several areas of spalling/scaling/cracked concrete with some exposed rebar. 5. The concrete ceiling outside where the old kitchen stairs were removed and in the basement near the boiler room, under the laundry room, in the furniture storage room and the old jail room were noted to have areas of spalling/scaling/cracked concrete with exposed rebar throughout. 6. The ceiling in the closet next to the Beauty Shop was noted to have an area of plaster crack/damage to the right side of the ceiling.
Based on observations made during an on-site inspection conducted on 12/03/2024, the facility failed to ensure that bathroom ventilation is vented to the outside in order to eliminate foul odors. EVIDENCE: The following was observed in the presence of the licensing inspector and staff person 1 and 2 on the day of inspection: 1. The ventilation system in multiple bathrooms of rooms located on the second floor are not vented to the outside.
Oct 21, 2024Routine11Report
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: 10/21/2024 8:50am until 2:00pm 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on staff record review, the facility failed to ensure that all staff received orientation and initial training within the first seven working days of employment. EVIDENCE: 1. The record for staff person 1, employed on 06/28/2024, did not contain documentation that this employee received orientation and initial training within the first seven days of employment. In an interview conducted with staff person 1 on 10/21/2024, staff person 1 expressed that this was correct.
Based on staff record review, the facility failed to ensure that staff records contained verification of the staff person receiving a copy of their current job description. EVIDENCE: 1. An email was received by the licensing inspector on 07/23/2024 that named staff person 1 as the administrator of record for the facility. 2. During the on-site inspection conducted on 10/21/2024, the licensing inspector observed that the record for staff person 1 did not have verification of receiving a copy of their current job description as the facility administrator. In an interview conducted with staff person 1 on 10/21/2024, staff person 1 expressed that this was correct.
Based on staff record review, the facility failed to ensure that a screening for tuberculosis occurred on or within seven days prior to the first day of work for all new employees. EVIDENCE: 1. The record for staff person 1, hired on 06/28/2024, has documentation that a screening for tuberculosis was not completed until 07/31/2024.
Based on resident record review, the facility failed to ensure that physical examinations and reports contained all required information. EVIDENCE: 1. The physical examination dated 05/06/2024 in the record for resident 1 and the physical examination dated 08/02/2024 in the record for resident 3 did not contain documentation of a statement that specifies whether the residents are or are not capable of self-administering medications.
Based on resident record review, the facility failed to ensure that individualized service plans ( ISP
Based on facility documentation review, the facility failed to ensure that a Health Department inspection was conducted annually. EVIDENCE: 1. The last Health Department inspection was noted to be dated 06/12/2023. In an interview with staff person 1 conducted on 10/21/2024, staff person 1 was not able to locate any documentation that the local Health Department was notified about the facility?s annual Health Department inspection being past due.
Based on observations of the facility medication carts and the facility medication management plan (MMP), the facility failed to ensure implementation of their MMP in regard to completing a controlled drug count. EVIDENCE: 1. The facility MMP has documentation on page 4 under An assigned Licensed Nurse/Registered Medication Aide will begin a shift by completing a controlled drug count that a controlled drug count sheet is to be signed by individual going off duty, and the one accepting the responsibility for the controlled drugs, and medication administration. 2. The control drug count record for October 2024 for medication cart 1 did not have staff signatures for on at 7am/off 7pm for counting the controlled medications on 10/13/2024 and 10/18/2024. 3. The control drug count record for October 2024 for medication cart 2 did not have staff signatures for off at 7am on 10/18/2024 and for on at 7pm/off 7am on 10/20/2024for counting the controlled medications.
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The record for resident 2 has documentation of a physician order dated 09/06/2024 for Methadone HCL 5mg, half a tablet (2.5mg) by mouth every day for pain. 2. A controlled count sheet for the Methadone for resident 2 has documentation on 09/25/2024 at 8pm that 1 pill is missing. In an interview with staff person 1 conducted on the day of inspection, staff person 1 expressed that on 09/25/2024 a second dose of Methadone was administered to resident 2 at approximately 8pm even though the order is for 1 pill daily.
Based on observations of the facility physical plant, the facility failed to keep the interior of the building clean and in good repair. EVIDENCE: 1. The carpet in the hallway on the first floor was noted to have numerous stains thorough out the floor.
Based on observations of the facility physical plant, the facility failed to post the finding of the most recent inspection of the facility. EVIDENCE: 1. During the on-site inspection conducted on 10/21/2024, the licensing inspector observed that the inspection notice from the 05/10/2024 inspection that was signed by the licensing inspector and the facility administrator on 07/03/2024 was not posted in the facility.
Based on staff record review, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: 1. The record for staff person 3, hired on 03/19/2024, has documentation that a sworn statement or affirmation was not completed until 07/19/2024.
May 10, 2024Routine
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: 05/10/2024 9:00am until 11:30am 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on observations made during an on-site inspection conducted on 05/10/2024, the facility failed to maintain the interior and exterior of the building in good repair and free of rubbish. EVIDENCE: The following was observed in the presence of the licensing inspector and staff person 1 on the day of inspection: 1. Bubbling/peeling paint/plaster was noted in several areas on the walls of the hallway outside of the Pine Room. 2. The wood near the drain spout outside of the dining room was noted to have paint/wood cracks damage. 3. The awning over the front porch was noted to have paint/wood damage to the left side of the awning. 4. The kitchen floor was noted to have several missing tiles in front of the utility cabinet near the refrigerator. 5. The tile for the back patio was noted to be removed and the patio is inoperable. 6. Multiple cracks were noted at the base of the brick/block walls outside of the activity room and wall along the edges of the back patio. 7. The support beams in the parking garage were noted to have several areas of spalling/scaling/cracked concrete with some exposed rebar. 8. The concrete ceiling outside where the old kitchen stairs were removed and in the basement near the boiler room, under the laundry room, in the furniture storage room, the old jail room, in the hallway outside of the pine room and in the pine room were noted to have areas of spalling/scaling/cracked concrete with exposed rebar throughout.
Based on observations made during an on-site inspection conducted on 05/10/2024, the facility failed to ensure that bathroom ventilation is to the outside in order to eliminate foul odors. EVIDENCE: The following was observed in the presence of the licensing inspector and staff person 1 on the day of inspection: 1. The ventilation system located in the bathrooms of rooms on the second floor and the common shower room located on the second floor (22 in total) are not vented to the outside.
May 10, 2024Complaint
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2024 9am until 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/01/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on resident record review and staff interviews, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training. EVIDENCE: 1. The record for resident 1 has documentation that the resident has a supra pubic catheter. The May 2024 medication administration record for resident 1 has documentation of staff initials for the cleaning of resident 1?s catheter site daily. In an interview with staff person 1 on 05/10/2024, staff person 1 expressed that staff records do not have documentation of receiving training in supra pubic catheter care.
Based on resident record review, the facility failed to ensure that individualized service plans ( ISP
Based on observations of the facility physical plant, the facility failed to record meal substitutions on the posted menu. EVIDENCE: 1. The facility posted menu has documentation that the lunch meal on 05/10/2024 is Pot Roast, Swiss Scallop Potatoes and Seasoned Green Beans. The LI observed that Pork Chops, Brussel Sprouts and Cheesy Grits were prepared and served for the lunch meal on 05/10/2024.
Oct 10, 2023Routine
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: 10/10/2023 9:20am until 1:30pm 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on resident record reviews, the facility failed to ensure that a fall risk rating was completed when a resident assessed as assisted living level of care falls. EVIDENCE: 1. The uniform assessment instrument ( UAI
Based on resident record reviews, the facility failed to ensure individualized service plans ( ISP
Based on resident record review, the facility failed to ensure that resident records were kept current. EVIDENCE: 1. The record for resident 4 has a physician order dated 09/18/2023 for home health services for wound care. The record for resident 4 does not have home health notes to include documentation of wound care being completed for resident 4.
Based on observations of the facility medication carts, the facility to implement their medication management plan in regards to methods to prevent the use of outdated medications. EVIDENCE: 1. The facility medication management plan has documentation on page 4 that ?Outdated, contaminated and discontinued drugs are to be removed from the medication cart immediately, and place in the locked medication room? and ?medications will be disposed of immediately after it has been discontinued, expired or after a residents? passing?. 2. An open Insulin Aspart Flex Pen for resident 7 was observed in the drawer on medication cart 1. The insulin did not contain a date that is was opened to ensure that it is disposed of within 28 days of opening per the manufacturers instructions.
Based on observations made during an on-site inspection conducted on 10/10/2023, the facility failed to maintain the interior and exterior of the building in good repair and free of rubbish. EVIDENCE: The following was observed in the presence of staff 4 and collateral witness 1 on the day of inspection: 1. Bubbling/peeling paint/plaster was noted in several areas on the walls of the hallway outside of the Pine Room. 2. The wood near the drain spout outside of the dining room was noted to have paint/wood cracks damage. 3. The awning over the front porch was noted to have paint/wood damage to the left side of the awning. 4. The flooring under the second window near the door in the dining room was noted to be spongy. 5. The kitchen floor was noted to have several missing tiles in front of the utility cabinet near the refrigerator. 6. The tile for the back patio was noted to be removed and the patio is inoperable. 7. Free standing water was noted on the silver area of the back patio. 8. Multiple cracks were noted at the base of the brick/block walls outside of the activity room and wall along the edges of the back patio. 9. The parking garage under the patio adjacent to Colonial Ave was noted to have several areas of stains on the concrete on the ceiling. A green substance was present on many of these stains. Wet bricks were noted in several areas of the garage walls. Free standing water was observed on the garage floor and several areas of active dripping water was noted from the garage ceiling. 10. The support beams in the parking garage were noted to have several areas of spalling/scaling/cracked concrete with some exposed rebar. 11. The concrete ceiling outside where the old kitchen stairs were removed and in the basement near the boiler room, under the laundry room, in the furniture storage room, the old jail room, in the hallway outside of the pine room and in the pine room were noted to have areas of spalling/scaling/cracked concrete with exposed rebar throughout. 12. Free standing water was noted on the floor of the pine room and the furniture storage room and several areas of active dripping water were observed coming from the ceiling.
Based on observations made of the facility physical plant, the facility failed to ensure that all areas used by residents maintained a temperature of 72? F while residents are awake. EVIDENCE: 1. At 10:30am on the day of inspection the temperature in the facility dining room was noted to be 65? F. As of 11:33am the temperature in the dining room was noted to be 67? F.
Based on observations made during an on-site inspection conducted on 10/10/2023, the facility failed to ensure that bathroom ventilation is to the outside in order to eliminate foul odors. EVIDENCE: The following was observed in the presence of staff 4 and collateral witness 1 on the day of inspection. 1. The ventilation system located in the bathrooms of rooms on the second floor and the common shower room located on the second floor (22 in total) are not vented to the outside.
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