Inspection Reports for
Karolwood Gardens Portsmouth
1 Bon Secours Way, Portsmouth, VA 23703, Portsmouth, VA, 23703
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Inspection Reports Summary
Covers 24 inspections · Nov 2021 – Oct 2025Visit Reason
This report covers all inspections and complaint surveys conducted at Karolwood Gardens at Portsmouth from November 18, 2021 to October 6, 2025.
Complaint Details
Eleven inspections were prompted by complaints regarding areas such as Resident Care and Related Services, Buildings and Grounds, Admission, Retention and Discharge of Residents, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Some complaint investigations found violations, while others did not support the allegations.
Findings
Across that history VDSS cited 100 violations under 60 distinct standards across 24 inspections, 19 with violations and 5 clean visits. Eleven inspections were prompted by a complaint.
Violations (94)
22VAC40-90-40-B: Failed to obtain criminal history record report on or prior to 30th day of employment for each employee.
22VAC40-73-610-B: Menus and snacks for current week not dated and posted conspicuously; substitutions not recorded.
22VAC40-73-870-A: Interior and exterior of buildings not maintained in good repair and clean; dog feces and debris observed.
22VAC40-73-870-C: Inadequate provisions for collection of garbage and waste material; bulk trash observed.
22VAC40-73-870-E: Furnishings and equipment not kept clean and in good repair; multiple chairs in disrepair.
22VAC40-73-870-G: Grounds not properly maintained; grass not mowed and bushes untrimmed.
22VAC40-73-1140-B: Direct care staff failed to attend at least 10 hours of cognitive impairment training within four months of employment.
22VAC40-73-45-A: Failed to provide evidence of liability insurance coverage according to licensed capacity tier.
22VAC40-73-50-B: Failed to retain written acknowledgment of receipt of disclosure by resident or legal representative.
22VAC40-73-325-B: Failed to ensure fall risk rating completed after a fall.
22VAC40-73-390-A: Failed to have written agreement/acknowledgment dated and signed by resident or legal representative at admission.
22VAC40-73-410-A: Failed to provide orientation for new residents and legal representatives including emergency procedures and call system use.
22VAC40-73-640-A: Failed to implement medication management plan preventing use of outdated medications; expired meds observed.
22VAC40-73-870-A: Interior and exterior of buildings not maintained in good repair and clean; debris and missing flooring observed.
22VAC40-73-990-C: Failed to document staff participation in practice exercises for resident emergencies at least every six months.
22VAC40-90-40-B: Failed to obtain criminal history record report on or prior to 30th day of employment for Staff #7.
22VAC40-90-40-H: Employed person convicted of barrier crime; Staff #6 convicted of felony barrier crime in 2006.
22VAC40-90-60-A: Failed to maintain original criminal history record report at facility for Staff #5.
22VAC40-73-710-B: Physical restraints used for discipline or convenience; Staff #4 terminated for restraining resident.
22VAC40-73-870-A: Interior and exterior of buildings not maintained in good repair and clean; furniture and trash piled outside.
22VAC40-73-870-D: Failed to keep free of infestations of insects and vermin; live bed bugs found in 5 rooms.
22VAC40-73-150-B: Failed to immediately employ new administrator or acting administrator after resignation or discharge.
22VAC40-73-870-I: Elevator inspection certificate expired; not kept current as required.
22VAC40-73-1150-A: Doors leading to unprotected areas not monitored or secured with alarms or devices as required.
22VAC40-73-460-D: Failed to provide supervision including attention to specialized needs such as wandering.
22VAC40-73-990-C: Failed to document staff participation in practice exercises for resident emergencies at least every six months.
22VAC40-73-150-B: Failed to immediately employ new administrator or acting administrator after resignation or discharge.
22VAC40-73-1120-F: Designated staff person for structured activities not on site at least 20 hours per week.
22VAC40-73-1090-A: Failed to assess residents by licensed psychologist or physician for serious cognitive impairment prior to admission to safe, secure environment.
22VAC40-73-1110-A: Failed to determine and document appropriateness of placement in special care unit for residents with serious cognitive impairment.
22VAC40-73-50-B: Failed to retain written acknowledgment of receipt of disclosure by resident or legal representative.
22VAC40-73-200-D: Failed to maintain certificate or documentation of staff meeting training requirements in personnel record.
22VAC40-73-210-B: Failed to ensure direct care staff attend required annual training hours including infection control.
22VAC40-73-250-D: TB risk assessments not completed timely for staff.
22VAC40-73-260-A: Failed to maintain current first aid certification for direct care staff.
22VAC40-73-320-A: Failed to ensure physical examination by independent physician within 30 days preceding admission.
22VAC40-73-390-A: Failed to have written agreement/acknowledgment dated and signed by resident or legal representative at admission.
22VAC40-73-620-A: Failed to ensure dietary oversight conducted every six months by dietitian or nutritionist.
22VAC40-73-680-C: Failed to administer medications within one hour before or after scheduled time; multiple missed doses documented.
22VAC40-73-690-B: Failed to ensure licensed health care professional review medications every six months for residents assessed for assisted living care.
22VAC40-73-980-C: Failed to check first aid kits monthly for completeness and expiration dates.
22VAC40-73-990-C: Failed to document staff participation in practice exercises for resident emergencies at least every six months.
22VAC40-90-40-B: Failed to obtain criminal history record report on or prior to 30th day of employment for multiple staff.
22VAC40-73-120-A: Failed to ensure orientation and training occur within first seven working days of employment.
22VAC40-73-250-C: Failed to maintain personal and social data including verification of receipt of job description in staff records.
22VAC40-73-250-D: Failed to maintain timely TB risk assessments for staff.
22VAC40-73-260-A: Failed to maintain current first aid certification for direct care staff.
22VAC40-73-640-A: Failed to ensure accurate counts of controlled substances when medication staff changes.
22VAC40-73-680-C: Failed to administer medications within one hour before or after scheduled time; multiple missed doses documented.
22VAC40-73-120-A: Failed to ensure orientation and training occur within first seven working days of employment.
22VAC40-73-260-A: Failed to maintain current first aid certification for direct care staff.
22VAC40-73-560-C: Failed to retain physician's notes and progress reports in resident's record.
22VAC40-73-440-A: Failed to complete residents' Uniform Assessment Instrument (UAI) at least annually.
22VAC40-73-460-H: Failed to provide personal assistance and care to meet residents' needs.
22VAC40-73-660-A-1: Medication cart not locked and unattended.
22VAC40-73-680-C: Failed to administer medications within one hour before or after scheduled time; multiple missed doses documented.
22VAC40-73-870-A: Interior of building not maintained in good repair and clean; vent dirty and flooring buckled.
22VAC40-73-880-C: Failed to provide air conditioning system maintaining temperatures not exceeding 80°F in resident areas.
22VAC40-73-40-B: Failed to obtain criminal history record report on or prior to 30th day of employment for staff.
22VAC40-73-120-A: Failed to ensure orientation and training occur within first seven working days of employment.
22VAC40-73-210-G: Failed to maintain documentation of training type, provider, hours, and dates in staff records.
22VAC40-73-250-C: Failed to maintain personal and social data including verification of receipt of job description in staff records.
22VAC40-73-260-A: Failed to maintain current first aid certification for direct care staff.
22VAC40-73-320-A: Failed to ensure physical examination by independent physician within 30 days preceding admission.
22VAC40-73-450-C: Failed to complete comprehensive individualized service plan within 30 days after admission.
22VAC40-73-640-A: Failed to prevent use of outdated medications; expired medications observed in carts.
22VAC40-73-680-C: Failed to administer medications within one hour before or after scheduled time; multiple missed doses documented.
22VAC40-73-680-I: MARs did not include diagnosis, condition, or indications for administering drugs or supplements.
22VAC40-73-690-G: Failed to act on pharmacy medication review recommendations.
22VAC40-90-30-B: Failed to complete sworn statement or affirmation for all employment applicants.
22VAC40-73-1090-A: Failed to assess residents for serious cognitive impairment prior to admission to safe, secure environment.
22VAC40-73-1110-A: Failed to determine and document appropriateness of placement in special care unit for residents with serious cognitive impairment.
22VAC40-73-250-C: Failed to maintain personal and social data including verification of receipt of job description in staff records.
22VAC40-73-325-A: Failed to complete fall risk rating by time comprehensive ISP completed for residents meeting assisted living criteria.
22VAC40-73-430-H-1: Failed to provide dated discharge statement signed by licensee or administrator at discharge.
22VAC40-73-450-C: ISP did not include description of resident's identified needs based on UAI.
22VAC40-73-640-A: Failed to prevent use of outdated medications; expired medications observed in carts.
22VAC40-73-870-A: Interior of building not maintained in good repair and clean; vents dirty, porch screening ripped, wallpaper peeling, refrigerator dirty, debris and ladder hazards.
22VAC40-73-40-B-6: Failed to exercise general supervision and establish policies conforming to law; resident records missing current documents.
22VAC40-73-260-A: Failed to maintain current first aid certification for direct care staff.
22VAC40-73-320-A: Failed to ensure physical examination by independent physician within 30 days preceding admission.
22VAC40-73-325-B: Failed to complete fall risk rating at least annually and/or after a fall.
22VAC40-73-350-B: Failed to ascertain and document prior to admission if potential resident was a registered sex offender.
22VAC40-73-380-A: Failed to include all required documentation in resident's personal and social information at or prior to admission.
22VAC40-73-440-A: Failed to complete UAI prior to admission, annually, and with significant condition changes.
22VAC40-73-450-A: Failed to develop preliminary plan of care on or within seven days prior to admission and comprehensive ISP within 30 days after admission.
22VAC40-73-550-G: Failed to obtain written acknowledgment of receipt and review of residents' rights and responsibilities.
22VAC40-73-680-C: Failed to administer medications within one hour before or after scheduled time; multiple missed doses documented.
22VAC40-73-870-A: Interior of building not maintained in good repair and clean; vents dirty, broken light, missing cabinet, tripping hazards.
22VAC40-90-40-B: Failed to obtain criminal history record report on or prior to 30th day of employment for Staff #1.
22VAC40-73-40-B: Failed to obtain criminal history record report on or prior to 30th day of employment for staff.
22VAC40-73-610-B: Menus and snacks for current week not dated and posted conspicuously; substitutions not recorded.
22VAC40-73-610-E: Diet manual containing acceptable nutrition practices not current and readily available to food preparation personnel.
22VAC40-73-870-A: Interior and exterior of buildings not maintained in good repair and clean; vegetation growing in gutters and units in disrepair.
Report Facts
Violations cited: 100
Distinct standards: 60
Inspections on page: 24
Inspections with violations: 19
Complaint visits: 11
Employees mentioned
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