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: April 28, 2022 and April 29, 2022

Complaint Related: No

Areas Reviewed:

Part I General Provisions Part II Administration and Administrative Services Part III Personnel Part IV Staffing and Supervision Part V Admission, Retention and Discharge of Residents Part VI Resident Care and Related Services Part VII Resident Accommodations and Related Provisions Part VIII Buildings and Grounds Part IX Emergency Preparedness Part X Additional Requirements for Facilities that Care For Adults with Serious Cognitive Impairments

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1 resides in the safe, secure environment; however, the Assessment of Serious Cognitive Impairment forms documenting the assessment of Resident #1 indicate that Resident #1 is able to recognize danger or protect his/her own safety and welfare.
Plan of Correction:	Facility psychiatric PA will re-assess resident #1 to determine whether he/her is able to recognize danger or protect his/her own. There is no adverse effect on this resident. All other residents at special care unit have appropriate documents. Administrator or designee will review each resident on special care unit every 6 month for appropriate continuous placement. The resident of review will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: 1. Resident #1 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in the resident?s record.
Plan of Correction:	The documentation of the determination and justification on whether placement in the special care unit is appropriated for resident #1 by the administrator is placed in the resident?s record. Administrator will audit all residents on special care unit to assure each resident has the documentation of the determination and justification on whether placement in the special care unit is appropriated on their records. Administrator or designee will review resident pre-admission document to assure that appropriate documentation for special care unit is in place. Administrator or designee will review each resident on special care unit every 6 month for appropriate continuous placement. The results of review will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure personal and social data be maintained on staff and include verification that the staff person has received a copy of their current job description. Evidence: 1. The record of Staff #2 did not contain verification that Staff #2 received a copy of their current job description.
Plan of Correction:	Staff #2 will receive the current job description. The varication of that will be placed in staff #2?s file. Business Office Coordinator or designee will audit all staffs? personnel files to assure that all staff have received current job descriptions from Karolwood Gardens at Portsmouth. Moving forward, Business Office Coordinator or designee will make sure that new hires receive the current Job Description during the orientation. Business Office Coordinator or designee will audit new hire files twice a month to assure that the verification of staff received a copy of their current job description. The results of audit will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure that a fall risk rating was completed by the time the comprehensive ISP was completed for residents who meet the criteria for assisted living care. Evidence: 1. Resident #1 met the criteria for assisted living care upon admission on 2/23/2022; however, there was not documentation of a fall risk rating being completed by the time the comprehensive ISP was completed. The only fall risk rating in the record of Resident #1 was after a fall on 4/22/22.
Plan of Correction:	An updated fall assessment for resident #1 is completed There is no adverse effect on the resident Director of Resident Care or designee will audit residents record to assess the admission fall risk assessment is in place. Director of Resident Care or designee will audit new resident file monthly to assure the admission fall risk assessment are in place.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. The records for Resident #5 and Resident #6 did not contain a written discharge statement.
Plan of Correction:	Administrator will complete the Discharge Notification and Statement for resident #5 and #6. A facility wide audit for discharge statement will be conducted to assure the compliance. Administrator or designee will establish a weekly Discharge Notification and Statement calendar. Business Office Coordinator or designee will audit for discharge statement completion weekly. The result of audit will be presented to facility QAPI Committee for review or recommendations.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #1?s UAI (dated 2/10/22) states the resident is incontinent with bowel weekly or more; however, Resident #1?s ISP (dated 3/22/22) does not address a need for bowel incontinence. The UAI for Resident #1 also states the resident requires mechanical and physical assistance with walking and mobility; however, the ISP for Resident #1 states the resident needs supervision with walking and does not indicate a need for mobility. Additionally, the ISP indicated Resident #1 has a DNR; however, there is not one in the record as the resident is a full code. 2. Resident #2?s ISP (dated 4/18/22) indicates the resident has a no concentrated sweet diet; however, the physician order sheet for Resident #2 signed on 4/26/22 states the resident?s diet is NCS, NAS, mechanical soft texture, thin consistency. 3. Resident #3?s UAI (dated 4/21/22) states the resident needs only physical assistance with bathing and dressing; however, Resident #3?s ISP (dated 4/21/22) indicates the resident needs physical and mechanical assistance with bathing. The UAI for Resident #3 also indicates the resident requires supervision with dressing; however, the ISP states the resident requires physical assistance with dressing. 4. Resident #4?s UAI (dated 4/21/22) states the resident needs only physical assistance with bathing and dressing; however, Resident #4?s ISP (dated 4/21/22) indicates the resident needs physical and mechanical assistance with bathing and supervision with dressing. The UAI for Resident #4 indicates the resident requires physical assistance with transfers; however, the ISP states the resident does not require assistance. The ISP for Resident #4 also indicates the resident utilizes a walker; however, both the UAI and ISP for Resident #4 state the resident does not need assistance with walking or mobility. 5. Resident #7?s UAI (dated 3/29/22) states the resident requires mechanical assistance with bathing; however, Resident #7?s ISP (dated 3/29/22) indicates Resident #7 requires mechanical and supervision with bathing.
Plan of Correction:	The UAI and ISP for resident #1, #2, #3, #4 and #7 will be updated accordingly. There is no adverse effect on the residents. Director of Resident Care and LPN supervisor will conduct on site health care oversight to review all UAI and ISP for accuracy. Director of Resident Care or LPN Supervisor will audit UAI/ISP monthly for accuracy. The result of audit will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications. Evidence: 1. The following expired medications were observed in the medication carts at the facility: Montelukast 10 mg tablets expired 2/23/22 for Resident #4 and Allergy Relief 180mg tablets expired 4/8/22 for Resident #9.
Plan of Correction:	Resident #4 and #9: Nursing staff have discarded the expired medications identified. There is no adverse side effect on both residents. Nursing staff will audit all medications to assure that current medications are not expired. Director of Resident Care (DRC) or designee will re-educate nurses/RMAs on Medication administration policy and procedures. DRC or designee will conduct random medication expiration audit weekly. The result of audit will be presented to facility QAPI Committee for review or recommendation.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, 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. Additionally, in the courtyard of the safe, secure environment, the screening of the porch was ripped. In the Cedar Point neighborhood, the wallpaper in the living room/common area was noted to be lifted in pealing in various sections. A refrigerator in the kitchenette areas in one of the units on the first floor was noted to have brown substance inside. 2. Two stairwells were also observed throughout the inspection. One stairwell was noted to have debris which could pose as a tripping hazard if the stairwell is needed for an emergency. Additionally, a ladder was noted in a vertical position in an alcove of a stairwell.
Plan of Correction:	Maintenance Coordinator cleaned the vent and placed a new filter. A new screen for the porch at special care unit is installed. Peeling wallpaper in the living room on Cedar Point neighborhood has been taken care. Staff also cleaned the refrigerator on the first-floor kitchenette area. Maintenance coordinator had removed the debris and ladder during the survey. Maintenance Coordinator or designee will audit the vents to assure the cleanness. Nursing staff have cleaned all refrigerators in kitchenette areas. Maintenance Coordinator or designee will make environment rounds weekly. Any identified area will be taken care of timely. Certified Dietary Manager will audit refrigerators at each neighborhood kitchenette area for cleanness. The results of the rounds and audits will be presented to facility QAPI committee for review and recommendations.