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: March 24, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced complaint inspection by two Licensing Inspectors was initiated on 3/24/2022 from 8:36 am to 12:51 pm. A complaint was received by the department regarding allegations in the areas of resident care and related services. Records were reviewed, staff interviews conducted, and a tour of the safe, secure environment held. Any violations related or not to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1150-A
Complaint related:	No
Description:	Based on observation and interview, 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 for residents residing in a safe, secure environment. Evidence: 1. On 3/17/22, while touring the a safe, secure environment, a door to an electrical room was unlocked and led to a unlocked door that exits to the street. Staff were alerted that a door to the outside was opened; however, it did not identify what door was opened. 2. Staff #5 was notified and was able to rearm the alarm on the door; however, Staff #5 was unable to state why it was unarmed.
Plan of Correction:	The door to the electrical room was locked immediately. A 100% audit was completed by the Maintenance Director on all exit doors in the safe secure unit to ensure they were locked. The Administrator completed oversight of the audit. All staff were in-serviced regarding the importance of rounding and keeping the unit safe and secure by checking to ensure exit doors are always locked. The Safe and Secure Environment/Special Needs Unit Policy and Procedure was reviewed with staff during the in-service. The Maintenance Director will audit all exit doors on the secure unit 5 times a week for 8 weeks. Any issues will be reported to the Administrator. 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. Issues that cannot be immediately corrected will be reported to the Administrator for further guidance.
Standard #:	22VAC40-73-460-H
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: 1. On 03/24/2022, the facility did not have documentation that residents receive bathing at least twice a week in the safe, secure environment. On 3/23/22, documentation indicates 4 residents should receive a shower and skin check; however, only one residents is documented as receiving a shower. The facility does not consistently document if or when bathing is completed. 2. Staff #1 and Staff #2 acknowledged the documentation did not indicate if bathing was completed and was unable to verify at the time of the inspection.
Plan of Correction:	A 100% audit was completed by the Assistant Resident Care Coordinator on all current residents bathing schedules to ensure that personal assistance and care was provided to each current resident. The Resident Care Coordinator completed oversight once the audit was completed. All direct care staff were in-serviced regarding the importance of documenting bathing and skin checks of residents. Direct Care Staff reviewed the Provision of Personal Services Policy and Procedure during the in-service. The Assistant Resident Coordinator will audit the bathing and skin checks of all current residents 5 times a week for 8 weeks. Any issues will be reported to the Resident Care Coordinator. 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. Issues that cannot be immediately corrected will be reported to the Administrator for further guidance.