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: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 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: 07/20/2023. 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 07/11/2023 regarding allegations in the area(s) of: Part V Admission, Retention and Discharge of Residents. 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 #:	22VAC40-73-560-C
Description:	Based on record review and interview, the facility failed to ensure any physician's notes and progress reports in the possession of the facility be retained in the resident's record. Evidence: 1. There were no physician?s notes or progress notes/information pertaining to Resident #1?s wounds in their record. 2. Staff #1 acknowledged the facility had additional information; however, it was not provided during the inspection nor within the resident?s record for review.
Plan of Correction:	1. The needed documentation was obtained and entered into the medical record. 2. The Administrator, AIT, or designee will complete an audit on all current resident charts to ensure compliance with 22VAC40-73-560-C. 3. The Administrator, AIT, or designee will routinely audit resident charts to ensure ongoing compliance. 4. Audits will be reviewed in QAPI with any trends reported and a POC initiated as indicated.