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 24, 2023 and April 25, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-450-E

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/24/2023 from 8:50 am to 3:50 pm and 04/25/2023 from 8:40 am to 11:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-40-B
Description:	Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee. Evidence: 1. The criminal history record report was obtained on 12/22/2022 for Staff #6 (hired 8/30/2022), Staff #7 (hired 11/8/2022) and Staff #8 (hired 11/8/2022).
Plan of Correction:	1. Staff #6, 7 and 8 all have clear criminal history records. 2. Business Office Coordinator will audit all current staff to make sure all criminal history records are obtained within the 30 days of hire. 3. We have started a new practice that all CRC must be obtained before the orientation day. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-120-A
Description:	Based on record review, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment. Evidence: 1. Staff #5 was hired on 6/20/2022; however, their staff record does not include documentation of their staff orientation and initial training.
Plan of Correction:	1. Staff #5 has received some orientation on the date of hiring. She will receive all the intimal training and orientation. 2. Business office coordinator or designee will audit all recent new hires to make sure the staff orientations and initial training are complete per DSS regulation. 3. Administrator or designee will audit the new hire files weekly. 4. The result of audit will be presented to facility QAPI committee for reviewing and recommendations.
Standard #:	22VAC40-73-210-G
Description:	Based on record review, the facility failed to ensure there is documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: 1. The records for Staff #1, Staff #2, Staff #3, and Staff #4 indicate they have completed 18 hours of annual in-services; however, the documentation did not include the dates the types of training were individually completed.
Plan of Correction:	1. Staff #1, 2, 3 and 4 have completed 18 hours of annual in-services. 2. Facility will implement a new annual in-service form to indicate the dates, the types of training we individually completed. 3. Business office coordinator or designee will keep track of each staff's annual in-service requirement. 4. Annual in-service completion status will be presented to facility QAPI committee for reviewing and 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 included in the staff record. Evidence: 1. Staff #5's record did not include verification that the staff person has received a copy of their current job description and name and telephone number of person to contact in an emergency.
Plan of Correction:	1. Staff #5 will receive a copy the current job description. and name and telephone number of person to contact in an emergency will be kept on file. 2. Business office coordinator or designee will audit all current new hires to make sure the staff has received a copy of job description. And the emergency contact person's name and phone number are on file. 3. Move forward, administrator or designee will review each new hires file to make sure all required documents are in the file. 4. The result of audit will be presented to facility QAPI committee for reviewing and recommendations.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #2 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	1. Staff #2 has obtained a new first aid certificate on May 5, 2023. 2. Business office coordinator or designee will audit all current direct care staff''s fille to make sure all required certificates are in file. 3. Administrator or designee will conduct random audit of personal files to make sure the required certificates are on current on file. 4. The results of audit will be presented to facility QAPI committee for reviewing and recommendations.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure within the 30 days preceding admission, a person have a physical examination by an independent physician. Evidence: 1. Resident #6 admitted to the facility on 3/17/2023; however, their admitting physical examination was completed on 12/22/2022.
Plan of Correction:	1. Resident has been seen by the same physician in February 2023, she gave the verbal approve to our staff to use December's physical examination since there is no changes. 2. Director of Resident Care (DRC) will review all upcoming new admission to make sure the physical examination is within 30 days of the admission. 3. Administrator or designee will audit the new admissions to make sure the physical examinations are within 30 days of admission date. 4. The result of audit will be presented to facility QAPI committee for viewing and recommendations.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive ISP be completed within 30 days after admission and include a description of current identified needs and written description of what services will be provided to address identified needs based upon the UAI. Evidence: 1. Resident #4's record did not include a comprehensive ISP. 2. Resident #1's UAI (dated 5/16/2022) indicates the resident is incontinent of bowel and bladder weekly or more; however, Resident #1's ISP (dated 6/20/2022) does not address the resident?s incontinence needs. 3. Resident #6's UAI (dated 3/15/2023) indicates the resident requires supervision with bathing, dressing, toileting, transferring and is incontinent of bowel and bladder weekly or more; however, Resident #6's ISP (dated 3/17/2023) indicates the resident does not require any assistance for bathing, dressing, toileting, transferring or note any assistance needed for incontinence.
Plan of Correction:	1. Resident #4 will have the comprehensive ISP. Resident #1 ISP will address the incontinence care needs. Resident #6's UAI and ISP will be updated regarding her ADLs needs. 2. Director of resident care will audit current residents UAI and ISP to make sure the care needs are matched. 3. Administrator will randomly audit 5 charts monthly to make sure the UAI and ISP are accurately reflect resident?s care needs. 4. The result of audit will be presented to the facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophe 325 mg tablets expired 12/15/2022 for Resident #1, PRN Ondansetron 4 mg tablets expired 7/29/2022 and Multaq 400 mg tablets expired 10/28/2022 for Resident #10, two cards of PRN Acetaminophe 325 mg tablets expired 12/15/2022 and 12/16/2022 for Resident #11, two cards of PRN Acetaminophe 325 mg tablets expired 12/15/2022 for resident #12, One A Day Multivitamin tablets expired 01/2022 for Resident #13, PRN Benzonatate 100 mg capsules expired 1/19/2023 for Resident #14, PRN Benzonatate 200 mg capsules expired 1/7/2023 for Resident #15, and Acetamin 500 mg tablets expired 12/15/2022 for Resident #7.
Plan of Correction:	1. All identified expired medication of the residents are removed from the medication carts. 2. Director of Resident Care or designee will conduct medication carts audit to assure no expired medications would stay in the carts. MD will be notified for reordering the meds or to DC meds. 3. DRC or designee will re-educate the RMAs and or LPNs on medication storage policy. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-680-C
Description:	Based on observation and interview, 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. At 10:00 am on 4/24/2023, Staff #2 was observed administering 9:00 am scheduled medications on the 3rd floor, and indicated two residents, Resident #6 (7 medications) and Resident #10 (4 medications), had not received their 9:00 am scheduled medications. The following residents in the safe, secure environment also had not received their 9:00 am scheduled medications by 10:00 am on 4/24/2023: Resident #4 (3 medications), Resident #7 (6 medications), Resident #16 (8 medications), Resident #17 (9 medications), Resident #18 (9 medications), and Resident #19 (5 medications).
Plan of Correction:	1. The identified residents received their medication a little bit late than the scheduled hours. There is no adverse effects noticed. 2. We have been aggressively hiring for RMA LPNs. And we have been use agency staff to assit the medication administration. 3. Director of Resident Care will make rondom rounds during medication passing time to make sure RMA/LPN administer medication timely per nursing practice standard. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the MAR include the identified items in the standard. Evidence: 1. The following medications on Resident #1's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Aspirin 81 mg tablet, Metoprol Sub 100 mg tablet, Paroxetine 10 mg tablet, and Amlodipine 5 mg tablet. 2. The following medications on Resident #2's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Ensure. 3. The following medications on Resident #5's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Amlodipine 10 mg tablet, Aspirin 81 mg tablet, Melatonin 10 mg capsule, Olanzapine 5 mg tablet, Polyeth Glyc Powder, Vitamin D 3 tablet, and Vitamin E capsule. 4. The following medications on Resident #6's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Ferosol 325 mg tablet and Colestipol 1 mg tablet. Additionally, the facility obtained a list of medication orders from the resident's physician to include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug on 3/22/2023 for Resident #6; however, the April MAR 2023 did not include the orders for Aricept and Glucosamine. 5. The following medications on Resident #7's April MAR 2023did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Ensure 6. The following medications on Resident #9's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Amiodarone 200 mg tablet, Eliquis 2.5 mg tablet, Ferosul 325 mg tablet, and Trazodone 50 mg tablet.
Plan of Correction:	1. All needed diagnoses are added to MARs and POS for identified residents in survey samples. 2. Director of Resident Care and Administrator have reviewed all current resident's POS and MARs for May, any missing diagnoses are added accordingly. All medications have matching diagnoses in May's MARs and POS. 3. Director of Resident Care or designee will audit all new medications orders received to have matching diagnoses. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
Standard #:	22VAC40-73-690-G
Description:	Based on record review, the facility failed to act in response to the recommendations noted in subsection F of this section. Evidence: 1. A pharmacy medication review was conducted on 1/31/2023. Resident #5's review included a recommendation for physician review and response; however, there was no documentation that the recommendation was sent for physician review and response at the time of inspection.
Plan of Correction:	1. Physician review has been completed, all needed diagnosis are added to MAR/POS accordingly for resident #5. 2. There is no other recommendations from pharmacy review. 3. Move forward, Director of Resident Care make sure all pharmacy review recommendations are followed up timely. 4. The result of pharmacy review recommendations will be presented to facility QAPI Committee for review and recommendations.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. There is no sworn disclosure in Staff #5's record.
Plan of Correction:	1. Facility will receive the sworn statement from staff #5. 2. Business office Coordinator or designee will review the current staff's file to make sure all sworn statement are in the staff's records. 3. Business office coordinator will review each new hire to make sure all required documents are obtained and kept in the file. 4. The result of audit will be presented to the facility QAPI committee for review and recommendations.