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: Sept. 12, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 09/12/2024 from 12:50 pm to 2:10 pm. 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 09/02/2024 regarding allegations in the area(s) of: Additional Requirements for Facilities that Care for Adults for Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 55 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: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: All exits within the safe, secure environment observed. 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 #:	22VAC40-73-1150-A
Description:	Based on discussion, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Evidence: 1. On 09/02/2024, Resident #1 exited the safe, secure environment through an emergency exit door where the alarm was deactivated.
Plan of Correction:	Frequency of checking the door alarm is armed increased to every 30 min. All staff reeducated on how to verify door alarms are armed. Executive Director or designee ensure training of all new staff on verifying door alarms are armed properly.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and discussion, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. Resident #1 eloped from the safe, secure environment on 09/02/2024. 2. Resident #1 was found off the premises approximately 0.4 miles away.
Plan of Correction:	Frequency of checking the door alarm is armed increased to every 30 min. All staff reeducated on how to verity door alarms are armed. Education provided to all staff to verify location of all residents on the secured unit.
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. The facility 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 or designee will conduct emergency procedure practice now and every 6 months with all staff, as well as for any new staff upon hire.