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: Feb. 10, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted by a Licensing Inspector (LI) from the Eastern Regional Office on 02-10-2022 from 11:10 AM to 4:30 PM. There were 25 residents in care at the time of the inspection. Water temperatures were sampled, staff and resident interviews held, and lunch meal observed. LI reviewed also reviewed 3 staff records, 5 resident records, emergency supply, and conducted a medication pass observation. LI followed up on violations received from the initial 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. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-40-B-6
Description:	Based on record review, the facility failed to exercise general supervision over the affairs of the licensed facility and establish policies and procedures concerning its operation in conformance with applicable law, this chapter, and the welfare of the residents. Evidence: 1. The new ownership attained responsibility on 12-01-2022; however, at the time of inspection, resident records were without the following current documents: Disclosure Statement, Resident Agreements, written assurance, and documents pertaining to residents residing in a safe, secure environment.
Plan of Correction:	Facility staff will provide current residents with Disclosure Statement, Resident Agreements, writing assurance and documents pertaining to resident residing in a safe, secure environment. There is no resident that is affected by this practice. When new resident moves in or should the ownership change, facility staff shall provide residents with Disclosure Statement, Resident Agreements, writing assurance and documents pertaining to resident residing in a safe, secure environment per VA Standards for Licensed Assisted Living Facilities. Administrator or designee will monitor for the compliance. The result of audit will be presented to facility?s QAPI committee for review and/or recommendations.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, 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: 1. Staff #4 works as a Certified Nursing Assistant and does not have a current certification in first aid. 2. Staff #1 acknowledged that Staff #4 does not have a current first aid certification on record.
Plan of Correction:	Staff #1 has obtained their new first aid certificate. Business Office Coordinator will audit other C.N.A.s to assure they have current first aid certificate. Director of Resident Care or designee will re-educate nursing staff on P/P and regulations on First Aid certificate and CPR. Business Office Coordinator will audit monthly for First Aid Certificate and CPR compliance. The results of audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure within the 30 days preceding admission, a person have a physical examination by an independent physician. The facility also failed to complete an annual risk assessment for tuberculosis on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The Report of Resident Physical Examination for Resident #5 dated the examination as 11-05-2021; however, the physician signed and dated the report on 02-01-2022. 2. Resident #1, Resident #3, and Resident #4 did not have current risk assessments for tuberculosis in their resident record.
Plan of Correction:	A qualified staff will complete the annual risk assessment for tuberculosis for resident #1, #3 and #4. Nursing staff will audit other resident?s charts to assure the annual risk assessments for tuberculosis are completed. Director of Resident or designee will re-educate nursing staff of P/P annual risk assessment for TB for resident. Director of Resident Care or designee will audit monthly for risk assessment for TB for resident. The results of audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility to ensure that a fall risk rating was completed at least annually and/or after a fall. Evidence: 1. Resident #1 had documentation of a fall on 12-27-2021; however there was not documentation of a fall risk rating being completed after this fall. 2. Resident #3 had documentation of a fall on 02-05-2022; however, there was not documentation of a fall risk rating being completed after this fall. 3. Resident #2 and Resident #4 meet the criteria for assisted living care; however, there was not documentation of a fall risk rating being completed in their records.
Plan of Correction:	Nursing staff will complete the fall risk rating for resident #1, #3, #2 and #4. Director of Resident Care or designee will audit other resident?s chart to assure the appropriated fall risk rating are completed. Director of Resident Care or designee will re-educate nursing staff on P/P fall risk rating. Director of Resident Care or designee will audit the chart for new resident and resident that had fall to assure the fall risk rating is completed accordingly. The results of audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #2 admitted to the facility on 01-11-2022; however, there was no sex offender screening documented in the resident?s record. 2. Resident #3 also did not have a sex offender screening documented in the resident?s record.
Plan of Correction:	Resident #2 and #3 sex offender screening documentations are located from the ?Sex Offender Check? binder. There is no affect for other residents. Facility staff will make the ?Sex Offender Check? documentation binder available to licensure staff at all times. Business Office Coordinator or designee will audit all new admission to assure the Sex Offender screening is completed prior to admission. The results of audit will be presented to facility QAPI for review and or recommendations.
Standard #:	22VAC40-73-380-A
Description:	Based on record review, the facility failed to ensure prior to or at the time of admission to an assisted living facility, all required documentation was included in the residents personal and social information. Evidence: 1. Resident #5?s record does not include the following: birthplace; marital status; service in the armed forces, if applicable; lifetime vocation, career, or primary role; special interests and hobbies; information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable; previous mental health or intellectual disability services history, if any, and if applicable for care or services; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services.
Plan of Correction:	Resident #5?s Resident Personal and Social Information form will be updated on March 14, 2022. Business Office Coordinator or designee will audit the new moved-in residents from 12/01/2022 to assure all required documentation is included in the Resident Personal and Social Information Form. Administrator will re-educate marketing director on: ALF regulation on: Prior to or at the time of admission, all required documentation should be included in the resident's personal and social information. Business Office Coordinator will audit the compliance. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete a UAI for residents prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: 1. Two of the five residents reviewed did not have a current UAI: Resident #1?s last UAI dated 09/02/2019 and Resident #4?s last UAI dated 1/19/2019. 2. Resident #5 was admitted on 02-01-2022. The Report of Resident Physical Examination signed by the physician on 02-01-2022 indicates the resident is not capable of self-administering medication; however, the UAI completed 01-31-2022 states the resident will take their medication without assistance. The Individualized Service Plan for Resident #5 dated 01-31-2022 also states the ?resident can self-administer medications.? 3. Staff #1 acknowledged the discrepancy between Resident #5?s Report of Resident Physical Examination and the UAI. Staff #1 confirmed since admission on 02-01-2022, Resident #5 has self-administered their medications.
Plan of Correction:	A: The qualified staff will complete the UAIs for resident #1 and #4. Resident #5 has been capable of self-administer the medications. Their physician will re-evaluate him when visits him. Resident #5 is planned to return home on March 15, 2022. B: Nursing staff will audit all resident charts to assure the annual UAIs are completed. There is no affect on resident #5 or any other residents. C: Administrator will create a calendar schedule to remind qualified staff to conduct Annual UAIs for residents. Administrator will re-educate Director of Resident Care and licensed nurse on UAI related regulations. Director of Resident Care or designed will audit residents that are self-administer medications to assure the MD order, UAI and ISP all indicate resident is able to self-administer the medications. D: Administrator or designee will audit UAI monthly. The results of audit will be presented to facility QAPI for review and or recommendations. Director of Resident Care or designee will audit the residents that are self-administer medications to make sure the MD order, UAI and ISP all match. The results of audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure on or within seven days prior to the day of admission a preliminary plan of care be developed. The facility also failed to ensure a comprehensive individualized service plan be completed within 30 days after admission and reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #4 did not have an individualized service plan (ISP) in their resident record. Additionally, Resident #1 did not have a current ISP in the record as the last dated ISP was 09/02/2019.
Plan of Correction:	Qualified staff will complete ISP for resident #4 and #1. Nursing staff will audit resident charts to assure all residents have current ISP. Administrator will create a calendar schedule to remind qualified staff to conduct Annual ISP for residents. Administrator will re-educate Director of Resident Care and licensed nurse on ISP related regulations. Administrator or designee will audit resident charts monthly to assure the ISP are completed accordingly. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to obtain written acknowledgment of the receipt and review of the rights and responsibilities of residents in assisted living facilities with the resident's, his legal representative's or responsible individual. Evidence: 1. Three of the five residents reviewed did not have current written acknowledgment of the receipt and review of the rights and responsibilities of residents in assisted living facilities with the resident's, their legal representative's or responsible individual: Resident #1?s last review dated 09/02/2019, Resident #3?s last review dated 06/18/2020, and Resident #4?s last review dated 07/09/2019.
Plan of Correction:	Facility staff will review the rights and responsibilities of residents in ALF with the POAs for resident #1, #3 and #4, and receive the written acknowledgement. Facility staff has started the annual review of the residents? rights and responsibilities with residents or POAs. The written acknowledgement will be received afterwards. January of each year is dedicated for annual resident rights and responsibilities of residents in ALF review. Business office Coordinator or designee will monitor for the compliance in January of each year. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-680-C
Description:	Based on record review, 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: 1. From 02/01/2022-02/09/2022, there were occasions residents did not receive their medication as they were not notated as administered on the resident?s MAR. Resident #1 missed 5 doses of Aquaphor Ointment (2/2/22, 2/4/22, 2/8/22, 2/9/22, and 2/10/22), 1 dose of Carvedilol 3.125 mg tablet (2/4/22), 1 dose of Calcium/D3 600 mg-400u tablet (2/4/22), and 1 dose of Eliquis 2.5 mg tablet (2/4/22). Resident #2 missed 1 dose of Acetaminophen 325mg tablet (2/2/22), 3 doses of Amlodipine 10 mg tablet (2/2/22, 2/3/22, and 2/9/22), and 1 dose of CO Q-10100mg capsule (2/10/22). Resident #3 missed 1 dose of Vitamin D3 tablet (2/4/22). Resident #4 missed 1 does of Donepezil 5mg tablet (2/2/22) and 1 does of Montelukast 10 mg tablet. 2. Resident #1?s order for Carvedilol 3.125mg tablet has a parameter that reads hold for SBP less than 105, or DBP less than 45, or Pulse less than 60; however, the MAR for Resident #1 documents the medication as administered and does not include documentation of the resident?s blood pressure and pulse at 1700 to ensure it is within the parameters for administration. 3. The MAR for Resident #3 includes a PRN order for Acetaminophe 325 mg tablet and Bengay vansh gel; however, these two items were not on the medication cart.
Plan of Correction:	A: There are no adverse effects on resident #1, #2, #3 and #4. Director of Resident Care or designee will review the MARs to identify if there is missing signatures holes on MARs. Director of Resident Care or designee will re-educate the RMA/Nurses on P/P Medication administer and documentation. A new shift to shift report including the audit of signatures to indicate the medications are administered will be initiated. Director of Resident Care or designee will monitor weekly, then twice a month to assure the compliance. The results of audit will be presented to facility QAPI committee for review and or recommendations. B: There was no adverse effect on resident #1. Director of Resident Care or designee will audit other residents that have BP and Pulse parameters for medications orders are followed accordingly. Director of Resident Care or designee will re-educate RMAs/Nurse on P/P medication administration. Director of Resident Care or designee will monitor weekly, then twice a month to assure the compliance. The results of audit will be presented to facility QAPI committee for review and or recommendations. C: Resident #3 has received her Tylenol and Bengay vansh gel from pharmacy. No other resident is affected. Director of Resident Care or designee will re-educate RMAs/Nurse to reorder resident medications timely. Director of Resident Care or designee will monitor medication carts monthly to assure residents have medications available. The results of audits will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility, a vent in the common area of the safe, secure environment was observed to have grey colored substance. The bathroom of Resident #3 was also observed to have a broken light above the sink and missing cabinet in vanity. A threshold on the first floor in the Cedar Point neighborhood was noted as being held down by black tape which could pose as a tripping hazard. 2. Staff #1 acknowledged the aforementioned areas in need of repair.
Plan of Correction:	Maintenance Coordinator has repaired the aforementioned areas on February 15, 2022. No resident is affected. Staff are reminded to report any needed repair to maintenance staff timely. Maintenance Coordinator or designee will make weekly rounds to assure any broken items are repaired timely. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-90-40-B
Description:	Based on 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: 1. At the time of the inspection on 02-10-2022, Staff #1 (hired 12-01-2021) did not have a completed criminal history record report. 2. Staff #1 acknowledged the facility did not obtain a criminal history record reports within the required timeframe.
Plan of Correction:	Staff #1?s criminal history record report request has been sent to Virginia State Police. All new hires since 12/01/2021 either have criminal history records in the file or the results are pending from Virginia State Police. Business office Manager or designee will obtain a criminal history record report from Virginia State Police for new hires on or prior to the 30th day of employment. Administrator or designee will audit new hire?s personnel record to assure the CRR is obtained on or prior to the 30th day of employment for each employee. The results of audit will be presented to facility QAPI committee for review and or recommendations.