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 23, 2024

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:

22VAC40-73-670

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: 04/23/2024 from 8:30 am to 3:06 pm. 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: 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: 5 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1 (admitted 4/10/2024) and Resident #3 (admitted 10/27/2023) did not have a completed assessment of serious cognitive impairment in their records.
Plan of Correction:	New admission packets updated to have complete serious cognitive impairment assessment forms. Executive Director, Resident Care Coordinator, or designee to review all new admission to secure environment has all required documentation prior to moving into the community.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #1 (admitted 4/10/2024) and Resident #3 (admitted 10/27/2023) did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	Documentation of approval for placement in special care unit to be completed for residents #1 and #3. Executive Director or Resident Care Coordinator to ensure form is completed and in file of any resident moving into community?s special care unit.
Standard #:	22VAC40-73-50-B
Description:	Based on record review, the facility failed to retain written acknowledgment of the receipt of the disclosure by the resident or his legal representative. Evidence: 1. Upon review of Resident #1?s record, there was no written acknowledgment of the receipt of the full disclosure by the resident or their legal representative.
Plan of Correction:	Disclosure will be resent to resident #1?s legal representative for initials and signatures. All new admission packets will be reviewed for all required admission documents by the Executive Director or designee.
Standard #:	22VAC40-73-200-D
Description:	Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250. Evidence: 1. Staff #5 works at the facility as direct care staff; however, their record did not include a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section.
Plan of Correction:	Audit of all current staff files to ensure requirements to provide care are present in the file. Any staff member missing documentation will be removed from the schedule until appropriate documentation is provided. Executive Director or designee to review all new hire documentation prior to the first day working with residents to ensure appropriate training has been completed.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and interview, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments. Evidence: 1. Staff #1 was unable to provide documentation of 2023 annual training for Staff #5.
Plan of Correction:	Audit to ensure that all current staff members have the required annual training going forward. Executive Director, Resident Care Coordinator, or designee to conduct monthly audits of staff education to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, 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. The risk assessment shall be no older than 30 days. Evidence: 1. Staff #2 was rehired on 05/23/2023; however, the only TB risk assessment for Staff #2 was completed on 03/17/2024. 2. Staff #3 was hired on 08/14/2023; however, the initial TB risk assessment in the record for Staff #3 was completed on 02/21/2023. 3. Staff #4 was hired on 01/08/2024; however, the initial TB risk assessment in the record for Staff #4 was completed on 03/17/2024.
Plan of Correction:	Executive Director, Resident Care Coordinator, or designee to review all new hire documentation prior to first day working with residents to ensure TB risk assessment has been completed.
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 #5 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	Audit to ensure that all current staff members have the required first aid training. Any staff member with missing or expired first aid training will be removed from the schedule until they have appropriate training completed. Executive Director, Resident Care Coordinator, or designee to conduct monthly audits of staff education to ensure ongoing compliance.
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 #1 admitted to the facility on 04/10/2024; however, their record did not include a completed physical examination.
Plan of Correction:	Executive Director, Resident Care Coordinator, or designee to review physical examination paperwork prior to admission of any new residents, to ensure that exam paperwork is completed in its entirety.
Standard #:	22VAC40-73-390-A
Description:	Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator. Evidence: 1. The facility was unable to provide documentation there was a written agreement/acknowledgment of notification dated and signed by the appropriate legal representative for Resident #1 (admitted 04/10/2024).
Plan of Correction:	All admission packets will be reviewed for all required admission documents by the Executive Director or designee.
Standard #:	22VAC40-73-620-A
Description:	Based on record review, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist. Evidence: 1. The last dietary oversight completed was completed on 2/20/2023.
Plan of Correction:	Executive Director to coordinate with a registered dietician to conduct dietary oversight for the community every six months.
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. Resident #1 admitted to the facility on 4/10/2024; however, the April 2024 MAR for Resident #1 does not document medication administration until 4/12/2024. Additionally, the 8:00 am and 9:00 am medications (total of 6 medications) for Resident #1 were not documented as administered on 4/21/2024. 2. The April 2024 MAR for Resident #2 shows the following medications were not administered on the following days: Atorvastatin 40 mg tablets from 4/15/24-4/17/24 (3 doses), Buspirone 5 mg tablet on 4/7/24, Clopidogrel 75 mg tablet from 4/20/24-4/22/24 (3 doses), Diclofenac gel on 4/4/24, 4/14/24, and 4/15/24, Gabapentin 600 mg tablet on 4/4/24, 4/9/24, 4/14/24, and 4/15/24 (4 doses), Mirtazapine 7.5 mg tablet from 4/1/24, 4/2/24, and 4/4/24 (3 doses), Omeprazole 20 mg tablet on 4/9/24, Sertraline 100 mg tablet on 4/18/24-4/19/24 (2 doses), and Vitamin B-12 1000 mcg tablet on 4/19/24. 3. During a medication observation on 4/23/2024 with Staff #2, the following medications were not available for administration for Resident #3: Memantine 10 mg tablet, Atenolol 50 mg tablet, and Hydroxyz 25 mg tablet. Additionally, the April 2024 MAR for Resident #3 shows the following medications were not administered on the following days: Atenolol 50 mg tablet on 4/21/24, Gabapentin 100 mg capsule on 4/13/24, Hydroxyz on 4/17/24 and 4/19/24-4/21/24 (4 doses), and Memantine 10 mg tablet 4/16/24-4/22/24 (10 doses). 4. Resident #5 has an order to check blood sugar three times a day before meals; however, the April 2024 MAR for Resident #5 indicates the machine has not worked since at least 4/1/24 and does not document Resident #5?s blood sugars.
Plan of Correction:	Education will be provided to all RMA and LPNs on obtaining and reporting any missing medications for residents. Family education will be provided to ensure that all prescribed medications and supplies are available to staff or will be ordered through contracted pharmacy to ensure that residents are receiving all prescribed medications and treatments. New blood sugar machine was ordered and received for resident #5 on 5/1/2024. Resident Care Coordinator or designee to conduct weekly audits of MAR/TAR to ensure compliance with medication administration plan.
Standard #:	22VAC40-73-690-B
Description:	Based on record review, the facility failed to ensure for each resident assessed for assisted living care, except for those who self- administer all of their medications, a licensed health care professional, practicing within the scope of his profession, perform a review every six months of all the medications of the resident. Evidence: 1. Staff #1 was unable to provide documentation of a medication review within the last 12 months.
Plan of Correction:	Executive Director to coordinate medication review by licensed health care professional for all current residents and every six months going forward.
Standard #:	22VAC40-73-980-C
Description:	Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. There was no documentation of the monthly checks of the first aid kit from April 2023-February 2024.
Plan of Correction:	Monthly first aid kit checks are currently being performed. Executive Director, Resident Care Coordinator, or designee to audit compliance with completion of monthly checks.
Standard #:	22VAC40-73-990-C
Description:	Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. Staff #1 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of Correction:	Executive Director to develop documentation staff practice of resident emergencies and ensure practice is completed at least every six months.
Standard #:	22VAC40-90-40-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. Staff #6 was hired on 09/25/2023; however, their criminal history record report was obtained on 11/01/2023. 2. Staff #7 was hired on 09/18/2023; however, their criminal history record report was obtained on 11/06/2023. 3. Staff #8 was hired on 03/08/2024; however, there was not a completed criminal history record report for Staff #8.
Plan of Correction:	Staff #8 criminal history has been obtained and has cleared criminal history. Executive Director or designee to ensure criminal history reports are received by the 30th day of employment or staff member will be removed from the scheduled until report is obtained. Executive Director or designee to audit all pending criminal history records for new employees weekly.