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: May 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

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: 05/23/2023 from 2:45 pm to 3:35 pm. 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 05/04/2023 regarding allegations in the area(s) of: Resident Care and Related Services. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

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. The May MAR for Resident #1 indicates the following medications were not administered on the following days: Alprazolam 1mg tab on 5/8/23 (two doses), 5/10/23, 5/13/23, and 5/21/23, Clomipramine 50mg capsule on 5/8/23, 5/10/23, and 5/19/23, Famotidine 20mg tab on 5/1/23, 5/8/23, 5/10/23, and 5/13/23, Olanzapine 10mg tab on 5/10/23, 5/16/23, and 5/18/23, Trospium CL 20mg tab on 5/7/23, 5/10/23, and 5/21/23, Valacyclovir 1gm tab on 5/3/23 and 5/21/23, Azo Urinary 99.5 tab on 5/1/23, 5/2/23 (two doses), and 5/3/23 (two doses), Cefdinir 300mg capsule on 5/1/23 and 5/2/23, and Roflumilast 250mg tab on 5/1/23, 5/2/23, 5/3/23, 5/10/23, 5/12/23, and 5/16/23, Nitrofurantoin 100mg capsule on 5/10/23.
Plan of Correction:	Resident #1 has completed the oral antibiotic medication on the extended days. There are missing signatures on the MARs noticed. Staff assessed resident and there are no adverse effects noticed. We have been aggressively hiring for RMA, LPNs. And we have been using agency staff to assist the medication administration. Director of Resident Care or designee will re-educate the RMA, Licensed Nurses on P/P of the Medication Administration Director of Resident Care or designee will make random rounds during medication passing to assure that RMA/LPN follow the nursing practice standard to administer medication timely and document on MAR. The result of audit will be presented to facility QAPI committee for review and recommendations.