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: July 20, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

22VAC40-73-870 22VAC40-73-930

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: 07/20/2023 and 07/25/2023. 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 07/10/2023 (2) and 07/21/2023 (1) regarding allegations in the area(s) of: Part VI Resident Care and Related Services, Part VII Resident Accommodations and Related Provisions, Part VIII Buildings and Grounds, Part IX Emergency Preparedness, and Part X Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review, the facility failed to complete a resident?s UAI at least annually. Evidence: 1. The last UAI for Resident #1 was completed on 05/16/2022. 2. The last UAI for Resident #2 was completed on 04/11/2022.
Plan of Correction:	1. The UAIs for Resident #1 and Resident #2 were updated. 2. The Administrator, AIT, or designee will complete a 100% audit on UAIs to ensure all current residents UAIs are up to date. 3. Moving forward Administrator, AIT, or designee will complete a 100% audit once a month to ensure that all UAIs are up to date. 4. Audits will be reviewed in QAPI with any trends reported and a POC initiated as indicated.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: 1. The documentation provided by Staff #1 does not indicate the residents reviewed are receiving bathing at least twice a week. The following are the documented completion or attempts of bathing on the records reviewed from 7/1/23 to 7/25/23: Resident #1 ? 7/8/23, 7/14/23, 7/18/23, and 7/21/23, Resident #2 ? 7/12/23, 7/19/23, 7/22/23, and 7/26/23, Resident #3 ? 7/8/23, 7/12/23, and 7/14/23, Resident #4 ? 7/25/23, and Resident #5 ? 7/4/23. Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 require physical assistance with bathing per the resident?s UAIs.
Plan of Correction:	1. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 were bathed. a UAIs were updated to reflect assistance was needed for bathing. 2. AIT has made a new shower schedule that ensures that residents receive a shower at least twice a week. 3. AIT created a new shower documentation sheet for all residents. Staff will document on residents set shower days. 4. Administrator, AIT, or designee will complete a weekly 100% audit on shower sheet documentation at the end of each week for 1 month. These audits will be completed on the shower documentation audit sheet. The audit will be reviewed in QAPI. Any trends will be reported and a POC will be initiated as indicated.
Standard #:	22VAC40-73-660-A-1
Complaint related:	No
Description:	Based on observation, the facility failed to ensure the medication cart be locked. Evidence: 1. During a tour of the facility on 07/25/2023, the medication cart on the Cedar Point unit was observed to be unlocked and unattended.
Plan of Correction:	1. The medication cart was immediately locked. 2. Administrator, AIT, or designee will educate all Registered Medication Aides and LPNs on the violation. 3. RMAs and LPNs will be re-educated on 22VAC40-73-660A. 4. Administrator, AIT, or designee will complete rounds throughout the day to make sure that all medication carts are locked on daily rounds. Daily rounds will be reported in QAPI. Any trends will be discussed and POC initiated as indicated.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
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 July MAR for Resident #5 indicates Uribel 118 mg capsule to be administered four times every Monday, Wednesday, and Friday was not available or administered on 7/7/2023 and 7/10/2023.
Plan of Correction:	1. Resident #5 had no adverse reactions. The medication is available for resident #5. The medication is being administered per M.D. order. 2. The Administrator, AIT, or designee will complete training with all Registered Medication Aids and LPNs on the medication times and procedure if a medication is not available. 3. Administrator, AIT, or designee will audit 100% of resident?s MAR for medications not administered or medications not available 3xper week for 30 days. This audit will be completed on the newly created MAR audit sheet. 4. Any medication that is not available will be discussed in the daily stand-up meeting. Any trends will be reported to QAPI and a POC will be initiated as indicated.
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 on 07/20/2023, a vent in the dining room of the safe, secure environment was observed to have grey colored substance. Additionally, there was flooring within the hallway of the unit that was buckled and a potential trip hazard to residents.
Plan of Correction:	1. The vent in the dining room was cleaned. The flooring was adjusted and re-glued to the floor. 2. Maintenance Director or designee will audit all vents in the building during daily rounds. If a vent is observed to need cleaning housekeeping or designee will clean the vent. 3. Maintenance Director or designee will observe flooring on daily rounds. If any issues arise, they will be addressed accordingly. 4. Maintenance or designee will make rounds daily to ensure they are complying with 22VAC40-73-870-A. Any issues or trends will be reported to QAPI and a POC will be initiated as indicated.
Standard #:	22VAC40-73-880-C
Complaint related:	Yes
Description:	Based on observation, the facility failed to provide in all buildings an air conditioning system for all areas used by residents, including residents' bedrooms and common areas. Temperatures in all areas used by residents shall not exceed 80?F. Evidence: 1. During a tour of the facility on 07/20/2023 and 07/25/2023, portable AC units were observed within the common areas (two living room areas and the dining room) of the safe, secure environment. 2. On 07/25/2023 around 2:00pm, the dining room area temperature measured 81?F.
Plan of Correction:	1. A portable AC was installed in the dining room. 2. Maintenance Director or designee will make daily rounds of the building to check temperatures of building. If temperature is above 80 degrees. 3. AC Vendor will be notified of any temperature issue. Designee will ensure that AC Vendor addresses the issue in a timely manner. If there is an issue with the vendor, the Designee will notify AIT or Administrator immediately. 4. 22VAC40-73-880-C will be discussed in QAPI. Any issues or trends will be discussed and POC initiated as indicated.