VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Karolwood Gardens at Portsmouth
1 Bon Secours Way
Portsmouth, VA 23703
(757) 686-9100

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Nov. 18, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An initial inspection was initiated on 11-18-2021 and concluded on 11-19-2021. The Administrator contacted by telephone to initiate the inspection. The Administrator reported that the current census was 28. A Licensing Administrator and a Licensing Inspector conducted the on-site portion of the inspection on 11-19-2021. 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:

Standard #:	22VAC40-73-290-B
Description:	Based on observation and interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 11-19-2021, during a tour of the facility, the current on-site person in charge was not posted in the facility. 2. Staff #1 and Staff #2 acknowledged the name of the current on-site person in charge was not posted in the facility.
Plan of Correction:	1. Facility started to post the name of the current on-site person in charge at the front lobby area that is conspicuous to the residents and the public on 01/13/2022. 2. No resident is affected. 3. A new procedure has been developed to ensure the compliance: Resident Care Coordinator or designee will post the name of the current on-site person in charge daily. 4. Administrator or designee will audit daily to ensure the compliance. Any non-compliance will be corrected immediately. The results of audit will be presented to facility QAPI committee quarterly for review and recommendations.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. On 11-19-2021, during a tour of the facility with Staff #1 and Staff #2, a posted menu for meals and snacks for the current week was not observed in an area conspicuous to residents in the facility. 2. Staff #2 acknowledge a current menu for meals and snacks was not posted in an area conspicuous to residents in the facility.
Plan of Correction:	1. Menus for meals and snacks for the current week are dated and posted on each neighborhood Dining Room entrance area. 2. No resident is affected. 3. Dietary manager or designee will make sure the weekly menus are dated and posted to each neighborhood entrance area. 4. Administrator or designee will monitor weekly to ensure the menus are dated and posted. Any non-compliance will be corrected immediately. The results of audit will be presented to facility QAPI committee quarterly for review and recommendations.
Standard #:	22VAC40-73-610-E
Description:	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: 1. On 11-19-2021, during a tour of the facility with Staff #1 and Staff #2, 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:	1. A Diet and Nutrition Care Manual by Becky Dorner & Associates, Inc. is kept current and readily available to personnel responsible for food preparation in the kitchen. 2. No resident is affected. 3. Dietary manager or lead cook is responsible to ensure the diet manual is available for dietary staff. 4. Administrator or designee will audit monthly to ensure the dietary manual is current and readily available to dietary staff. Any non-compliance will be corrected immediately. The results of audit will be presented to facility QAPI committee quarterly for review and recommendations.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to the interior and exterior of all buildings are maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 11-19-2021, during a tour of the facility, vegetation growing both in and over the gutters at the front of the facility and in the assisted living courtyard was observed. 2. On 11-19-2021, during a tour of the facility, four of a ten bed unit were observed to be unable to be occupied by residents due to various states of repair. Units 207 and 208 had disconnected AC units and uninstalled bathroom sinks. Unit 203 also had a disconnected AC unit on the floor of the apartment. Unit 210 was being utilized for facility storage. 3. Staff #1 and Staff #2 acknowledged the condition of the units observed.
Plan of Correction:	1. Maintenance Coordinator has removed/cleaned the vegetation growing in and over the gutters at the front of the facility and in the assisted living courtyard in December 2021. Facility will order new P-tanks for suite 203, 207 and 208 and install them. A new bathroom sink will be installed to suite 207. All supplies stored in suite 210 have been removed. This suite has been cleaned and is ready for admission. 2. Maintenance Coordinator will assess all gutters to ensure they are free from vegetation growing. No resident is affected as this neighborhood has not been occupied after COVID-19 pandemic. 3. Maintenance Coordinator or designee will assess the facility gutters monthly to ensure they are free from vegetation growing or blockage. Maintenance Coordinator will repair or replace suite P-Tanks timely. 4. Administrator or designee will audit the gutters quarterly. Any identified issue will be corrected timely. Administrator or designee also will audit suite P-tanks randomly to ensure they are in working condition. The results of audits will be presented to facility QAPI committee quarterly for review and recommendations.