VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Karolwood Gardens at Norfolk
6403 Granby Street
Norfolk, VA 23505
(757) 451-2400

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Jan. 31, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced complaint inspection was initiated on 01/31/2022 and concluded on 03/03/2022. A complaint was received by the department regarding allegations in the areas of administration and administrative services, personnel, staffing and supervision, resident care and related services, and building and grounds. The licensing inspector conducted an on-site observation at the facility on 01/31/2022 and 02/14/2022. Residents and staff were interviewed. Records were reviewed. Based on the information obtained during this inspection, some of the allegations were valid. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. Evidence: 1. Staff #1 provided the staff schedule and timesheets for January 1-15, 2022. It indicates that over the course of the fifteen days reviewed there were 12 shifts two direct care staff members were on duty in the special care unit. The schedule also showed that Staff #4 who does not qualify as direct care staff was scheduled as working two shifts; however, Staff #4?s timesheet does not indicate they worked those two shifts.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on observation, record review, and discussion, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. In speaking with Staff #1 and Staff #2, both confirmed Resident #3 received Resident #4?s 6 am dose of insulin. There was no evidence of this medication error or actions in response to the incident in either Resident #3 or Resident #4?s record. 2. Staff #1 acknowledged the incident of the medication error was not reported to the regional licensing office.
Plan of Correction:	The incident was not reported until 6 hours after the incident. An incident report was completed regarding the incident for Resident #3. The N.P. was notified of the incident and told staff to monitor. N.P. visited resident the following day. Neither resident had ill effects from the incident. A 100% audit was completed on all current residents to ensure that all incidents per the standard were reported. An in-service will be completed by the Administrator/designee for all staff. The in-service will re-educate all staff regarding the facility standard on reportable incidents. Administrator/designee will complete an audit on the 24 hour report for 3x a week for 8 weeks on the newly created 24 hours Audit form to ensure the standard is met. Additional audits may be completed as part of the quarterly healthcare oversight and findings will be reported to the administrator. Any identified variances will be investigated and corrected as appropriate.
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure the facility have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans. Evidence: 1 A LPN or RMA is needed to administer medications. The facility did not have a LPN or RMA scheduled from 7a-11p according to the schedule provided by Staff #1 and Staff #2 at the following days/times: 1/3/22 (7a-3p) 1/4/22 (7a-3p) 1/6/22 (7a-9a). 2. Adequate staff in sufficient numbers are required to provide services to residents as determined by their assessments to meet their physical, mental and psychosocial well-being. The facility had 1 or 0 staff working as a CNA to cover the assisted living portion of the facility (1st and 3rd floor) according to the schedule provided by Staff #1 and Staff #2 at the following days/times: 1/3/22 (7a-3p), 1 CNA 1/4/22 (7a-3p), 1 CNA 1/5/22 (7a-3p), 0 CNA 1/6/22 (9a-3p), 1 CNA 1/7/22 (7a-11p), 0 CNA 1/11/22 (7a-3p), 1 CNA 1/12/22 (7a-3p), 1 CNA 1/13/22 (7a-3p), 1 CNA.
Plan of Correction:	The Resident Care Coordinator was scheduled/working on 1/3/2022, 1/4/2022 and 1/6/2022. The Administrator who is a PCA was scheduled/working on 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/11/2022, 1/12/2022 and 1/13/2022. The Resident Care Coordinator emailed the DSS Inspector the schedules and information above. A 100% audit of the current months Nursing Schedule was audited to ensure that it met the standard. An in-service will be completed by the Resident Care Coordinator/designee for all staff. The in-service will re-educate all staff regarding the facility standard for adequate staff in sufficient numbers. Administrator/designee will complete an audit of the nursing schedule for 3x a week for 8 weeks on the newly created Staffing Audit form. Additional audits may be completed as part of the quarterly healthcare oversight and findings will be reported to the administrator. Any identified variances will be investigated and corrected as appropriate.
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on observation, record review, and discussion, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. Staff #2 was unable to provide a signed physician?s order for the treatment for Ted Hose for Resident #3. Resident #3?s MAR states Ted Hose should be placed on every morning and removed every evening; however, the following days in January do not indicate they were placed on Resident #3?s legs: 1/2/22, 1/4/22, 1/7/22, 1/10/22, 1/11/22, 1/13/22, 1/14/22, 1/15/22, 1/17/22, 1/18/22, 1/20/22, 1/21/22, 1/24/22, and 1/30/22. 2. On 2/14/22, LI spoke with Resident #3 who states they have at times Ted Hose have not been placed and there have been times they have refused to wear Ted Hose as a result of ?sores? on their legs. Resident #3 was observed to not have Ted Hose on legs during interview. The MAR does indicate 4 occasions in January where the resident refused to have the Ted Hose placed. There were no indications of ?sores? noted on the resident?s leg in the resident?s record.
Plan of Correction:	Resident #3 has a signed physician?s order for the treatment for Ted Hose. A 100% audit was completed on all current residents to ensure that signed physician orders were completed per the standard. An in-service will be completed by the Resident Care Coordinator/designee for RMA/LPN staff. The in-service will re-educate all staff regarding the facility standard on signed Physician Orders. Resident Care Coordinator/designee will complete an audit on signed Physician Orders for 3x a week for 8 weeks on the newly created Signed Physician Order form. Additional audits may be completed as part of the quarterly healthcare oversight and findings will be reported to the administrator. Any identified variances will be investigated and corrected as appropriate.
Standard #:	22VAC40-73-680-J
Complaint related:	Yes
Description:	Based on observation, record review, and discussion, the facility failed to ensure the actions listed in the standard are met in the event of a medication error. Evidence: 1. In speaking with Staff #1 and Staff #2, both confirmed Resident #3 received Resident #4?s 6 am dose of insulin. There was no evidence of this medication error, actions in response to the error, or documentation of physician or family notification of error in either Resident #3 or Resident #4?s record. Initially, Staff #2 stated the incident occurred on 1/11/2022; however, later confirmed the incident occurred on 1/12/2022. Staff #2 was notified of the medication error after Resident #3 reported it to their family. Neither of the residents experienced negative side effects per Staff #1 and Staff #2. 2. Staff #1 acknowledged the medication error nor the actions in response to the error were documented in either Resident #3 or Resident #4?s record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish. Evidence: 1. While observing a medication pass with Staff #2 on 01/31/2022, a flickering light was noted on the ceiling of the common area of the safe, secure environment above where the medication cart was placed at that time. On 01/31/2022, ceiling tiles outside of Resident #1?s apartment were noted to have brown spotting. While in Resident #1?s apartment, the bathroom ceiling metal trim appeared to be not secured, and there was a light out above the vanity. On 01/31/2022, there were not any barriers or signs to limit the accessibility to the area where major repairs were underway on the two second floor units. 2. While on-site on 02/14/2022, Resident #2 has a memory box noted outside the apartment. The memory box appears to be from a previous resident and has the glass pushed in. While also the safe, secure environment, there is a refrigerator in the open kitchenette area. A sign on the refrigerator states for resident use only; however, there were noted lunch boxes in the refrigerator. Additionally, the wires of the light for the refrigerator were visible as well as there was a frozen brown substance throughout the freezer portion. There was also a flickering light noted in the dining room area in the unit.
Plan of Correction:	The flickering lights were changed immediately. Resident #1 ceiling tiles was repaired and secured. Major Repairs have yet to begin on the 2nd floor. On 1/31/2022 coded locks were installed on both entrance doors on the 2nd floor. The lunch boxes were removed immediately. The wire was adjusted in the refrigerator immediately. The Housekeeper cleaned the brown substance immediately. Family for Resident #2 did not provide any personal items for the memory box. The memory box glass is a plastic plex-glass material. The box was emptied, and the plastic was adjusted. A 100% audit was completed for the physical plant to ensure that the standard was met. An in-service will be completed by the Administrator/designee for all staff. The in-service will re-educate all staff regarding the facility standard for Buildings and Grounds. Maintenance Director/designee will complete an audit on Building and Grounds for 3x a week for 8 weeks on the newly created Building and Grounds form. Additional audits may be completed as part of the quarterly healthcare oversight and findings will be reported to the administrator. Any identified variances will be investigated and corrected as appropriate.