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: June 15, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

22VAC40-73-460-H

Comments:

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: 06/15/2023 from 9:45 am to 1:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three complaints were received by VDSS Division of Licensing on 06/01/2023 and 06/05/2023 regarding allegations in the area(s) of: 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, and Part VIII Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 50 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 Observations by licensing inspector: Lunch was observed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part VI Resident Care and Related Services and Part VIII Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-580-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure if the facility, through its policies and procedures, offers routine or regular room service, residents be given the option of having meals in the dining area or in their rooms, provided that there is a written agreement to this effect, signed and dated by both the resident and the licensee or administrator and filed in the resident's record. Evidence: 1. Resident #6 indicated they eat all their meals in their apartment which was confirmed with Staff #3; however, the resident?s record does not include a written agreement between the resident and the licensee or administrator of this arrangement.
Plan of Correction:	1. Resident #6 will be provided a written agreement to give the option of having meals in the dining area or in her room. 2. A written agreement to give the option of having meals in the dining area or in resident?s room will be provided to those who prefers to have the meals in their rooms. 3. Director of Resident Care or designee will monitor and audit the practice. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-680-C
Complaint related:	No
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 June MAR for Resident #2 indicates the following medications were not administered on the following days: Clopidogrel 75mg tablet from 6/9/23-6/12/23 and Atorvastatin 40mg tablet on 6/13/23. 2. The June MAR for Resident #3 indicates the following medications were not administered on the following days: Buspirone 10mg tablet from 6/1/23-6/14/23 and Fluticasone 50mg spray from 6/1/23-6/14/23. 3. The June MAR for Resident #6 indicates the following medications were not administered on the following days: Lidocaine Pain Relief on 6/13/23 and Melatonin 3mg tablet on 6/6/23. 4. The June MAR for Resident #7 indicates the following medications were not administered on the following days: Carvedilol 3.125mg tablet on 6/6/23 and 6/8/23 and Venlafaxine 75mg capsule from 6/1/23-6/15/23.
Plan of Correction:	1. There are no adverse effects noted from resident #2, #3, #6 and #7. 2. There are no effects on other residents. 3. Director of Resident Care or designee will conduct random audit during medication passing time weekly to assure the compliance. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the MAR contain the items identified in the standard. Evidence: 1. The MARs of Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, and Resident #7 did not include the name, signature, and initials of all staff administering medications.
Plan of Correction:	1. A master signature form includes name, signature and initials of all staff administering medications will be put in place for each MAR book. All RMA or LPN will fill out the form. 2. New hires or Agency staff will complete the master signature form upon the starting date. 3. Director of Resident Care will audit the Master Signature Form is completed per standard. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-720-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Upon review of Resident #1?s record, their ISP (dated 5/11/23) indicates the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.
Plan of Correction:	1. Resident #1 has been hospitalized since June 14, 2023. 2. Resident #1 POA was reminded to provide the facility the signed DNR form. They were also informed resident will be treated as FULL code till signed DNR form is received. ISP is updated to reflect the code status. 3. Director of Resident Care or designee will audit the resident?s ISP to assure the signed DNRs on of file. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-870-A
Complaint related:	No
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 dining room of the safe, secure environment was observed to have grey colored substance. Additionally, a fan was noted in a common area and is a potential trip hazard.
Plan of Correction:	1. Staff will clean the identified vent in the dinning room on MCU. The fan has been removed from the common area. 2. Housekeeping staff will check all vent in the dining rooms to assure they are clean. 3. Administrator or designee will audit the vent cleanness and monitor for any trip hazard during rounds. 4. The results of audit will be presented to facility QAPI committee for review and or recommendations.
Standard #:	22VAC40-73-930-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure there is a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. On 6/15/2023 around 10:32 am, the call bell of Resident #6 was pressed. After 10 minutes past, no staff were observed to respond. Around 10:45 am, the call bell of Resident #7 was pressed. After 10 minutes past, no staff were observed to respond. 2. Staff #3, Staff #4, and Staff #5 indicated they were unaware of the call bells as there were no pagers available on the first floor for notification.
Plan of Correction:	1. Facility maintenance coordinator placed order for six beepers immediately. Director of Resident Care provide her beeper to 1st floor staff. The beeper for 2nd floor was located the same day of survey. 2. Additionally, we have ordered the table bells for the residents. 3. Director of Resident Care or designee will in service residents and staff to use table bell as call bell for assistance. Director of Resident Care or designee will audit the beepers and table bells usage during rounds. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.