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: Nov. 21, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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: 11/21/2023. 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 11/16/2023 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 49 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 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: All medication carts reviewed. Additional Comments/Discussion: Inspection focused on submitted self-reported incident. 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 #:	22VAC40-73-120-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. The record of Staff #2 (hired 7/11/23) does not include documentation of their staff orientation and initial training.
Plan of Correction:	Audit of all staff records will be done to identify any other missing orientation and initial training. Any identified missing items will be completed and placed in the employee?s file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. Staff #2?s record does not include verification that the staff person has received a copy of their current job description.
Plan of Correction:	Audit of all staff records will be done to identify any other missing signed job descriptions. Any identified missing items will be completed and placed in the employee?s file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Staff #1 was unable to provide the results of a TB risk assessment for Staff #2 (hired 7/11/23).
Plan of Correction:	Audit of all staff records will be done to identify any other missing TB screenings. Any identified missing items will be completed and placed in the employee?s file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
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 (hired 7/11/23) worked as direct care staff and does not have a current certification in first aid.
Plan of Correction:	Audit of all staff records will be done to identify any other staff members missing current first aid. Any identified missing items will be given the opportunity to complete and update their first aid and proof of completion placed in their file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to ensure methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. Two count sheets and cards of Hydrocodone 5-325 mg tablets (approximately 40 tablets) for Resident #1 were unable to be located and accounted for on 11/15/2023.
Plan of Correction:	100% education to all med techs and LPNs to complete the ?Shift Change Verification? form and to ensure they are counting all cards and sheets to make sure they match and to report any discrepancies immediately to the RCC or Executive Director. RCC or designee will conduct weekly audits to ensure compliance.
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 following medications were not documented as administered on the November MAR for Resident #1: Desonide Cream on 11/01/2023, 11/02/2023, 11/05/2023, 11/07/2023, 11/08/2023, 11/11/2023-11/14/2023, 11/16/2023, 11/17/2023, and 11/20/2023, Estradiol Cream on 11/01/2023, 11/02/2023, 11/05/2023-11/09/2023, 11/11/2023-11/13/2023, 11/15/2023-11/17/2023, and 11/20/2023, Gabapentin 300 mg tab on 11/14/2023 and 11/20/2023, Gemtesa 75 mg tab on 11/13/2023 and 11/16/2023, Hydrocodone 5-325 mg tab on 11/05/2023, 11/14/2023, and 11/17/2023, Omeprazole 20 mg capsule on 11/01/2023-11/04/2023 and 11/06/2023-11/21/2023, and Stioloto Respimat on 11/02/2023 and 11/07/2023.
Plan of Correction:	RCC or designee will do daily audits x4 weeks of MAR to ensure proper documentation of medication administration. 100% education for all LPN and med techs will be completed on ensuring proper documentation of medication administration.