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: May 5, 2022 and May 6, 2022

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

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: 05/05/2022 from 8:27 am to 4:34 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: 38 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Observations by licensing inspector: Medication observations completed. Breakfast was observed. 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 #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to complete a risk assessment for tuberculosis on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Resident #4 (admitted 4/6/22) and Resident #7 (admitted 3/4/22) did not have documented results of a risk assessment for tuberculosis prior to admission or in their resident record. 2. Resident #5 and Resident #6 did not have documentation of a current risk assessment for tuberculosis in their resident record.
Plan of Correction:	Resident #4 and #7 completed a risk assessment for tuberculosis. There were no adverse effects on these residents. A 100% audit will be completed by the Assistant Resident Coordinator on all current residents to ensure that tuberculosis assessments were completed. The Resident Care Coordinator will complete oversight on the audit once it is completed. The Administrator will in-service the Marketing Director, Assistant Resident Coordinator and Resident Coordinator on the tuberculosis assessment being completed prior to admission. The Assistant Resident Coordinator will complete an audit on all new admissions for 3 months to ensure that tuberculosis assessments are completed prior to admission. The Resident Care Coordinator will complete frequent oversight on the audit. The audit will be presented to the QAPI Committee for review or recommendations.
Standard #:	22VAC40-73-440-D
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30- 110 for private pay individuals. Evidence: 1. Resident #3?s UAI dated 03/24/2022 does not indicate if the resident does or does not require assistance with walking. Resident #3?s ISP dated 03/30/2022 indicates the resident requires supervision and mechanical assistance with walking. 2. Resident #6?s UAI dated 04/07/2022 does not indicate if the resident does or does not require assistance with both bowel and bladder incontinence. 3. Resident #8?s UAI dated 04/15/2022 does not indicate if the resident does or does not require assistance with wheeling, stairclimbing or mobility. Resident #8?s ISP dated 04/15/2022 indicates the resident requires supervision with mobility with no indication of assistance for wheeling or stairclimbing.
Plan of Correction:	Resident #3?s UAI indicates that the resident requires assistance walking. Resident #6 UAI indicates that the resident needs assistance with both bowel and bladder. Resident #8 UAI and ISP indicates the resident does need help wheeling, stairclimbing is not performed. There were no adverse effects on these residents. A 100% audit will be completed on all current residents? UAIs/ISPs by the Administrator/designee to ensure the UAIs and ISPs are completed as required by 22VAC30-110. The Administrator/designee will complete an audit on 10 residents each month for 3 months to ensure that UAIs and ISPs are completed as required by 22VAC30-110. The audit will be presented to the QAPI Committee for review or recommendations.
Standard #:	22VAC40-73-550-C
Description:	Based on observation, the facility failed to ensure a resident?s right to be treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity be met. Evidence: 1. During a tour of the facility, two licensing inspectors observed two staff members providing personal care to Resident #11 as the door to the resident?s apartment was left open.
Plan of Correction:	The two staff members were educated on Resident Rights. Both staff members were issued a final warning regarding employment. The resident was interviewed by the Administrator to ensure that there were no adverse effects to resident #11. The Administrator apologized to the resident that the incident occurred. The Resident Care Coordinator will conduct an in-service with all current staff regarding resident right to be treated with courtesy, respect, and consideration as a person of worth, sensitivity and dignity. The Administrator will interview 10 residents a month for 3 months to ensure that Resident Rights are being maintained. The results of the interviews will be presented to QAPI Committee for review or recommendations.
Standard #:	22VAC40-73-580-C
Description:	Based on observation, the facility failed to ensure personnel be available to help any resident who may need assistance in reaching the dining room or when eating. Evidence: 1. During a tour of the facility, two residents were observed in one of the dining rooms on the first floor of the assisted living eating breakfast around 9:00 am. There were no personnel within sight to be available to help any resident who may need assistance in reaching the dining room or when eating.
Plan of Correction:	The two residents in the dining room on the 1st floor are independent with eating and reaching the dining room. There was a R.M.A. and C.N.A. assigned to the 1st floor. The staff were providing care when the inspectors were observing the 1st floor. There were no adverse effects on these residents. Staff are assigned to the 1st floor daily. The schedule is posted daily in the lobby area on the 1st floor. The Administrator, Resident Care Coordinator, Assistant Resident Coordinator, Department Heads and Person in Charge make rounds throughout their workday. Staff are assigned daily/each meal to the dining area. The Administrator, Resident Care Coordinator, Assistant Resident Coordinator, Department Heads and Person in Charge will continue to monitor each floor and dining areas during mealtime.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to the interior and exterior of all buildings are maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility, the outdoor area of the safe, secure environment and assisted living was observed. The following was observed in the safe, secure environment outdoor area: screening of screen porch door ripped and exposed wires by the outdoor lighting. 2. During a tour of the facility, multiple carpet stains in the community?s central activity space were observed.
Plan of Correction:	Screening on the screen porch area was repaired. The exposed wires by the outdoor lighting were repaired. The carpet in the activiy area was professionally cleaned prior to inspection. The stains on the carpet are permanent. The carpet will be replaced in that areas of the building. There were no adverse effects on the residents. The Maintenance Director was in-serviced on 22VAC40-73-870-A, effective rounding, and preventative maintenance. The Administrator and Maintenance Director will make rounds together weekly for 3 months to ensure that the requirements of 22VAC-73-870-A are met. The results of the rounds will be presented to the QAPI Committee for review or recommendations.
Standard #:	22VAC40-73-930-A
Description:	Based on observation and interview, the facility failed to ensure a signaling device is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance. Evidence: 1. While on-site on 05/05/2022, it was indicated residents are to use hand bells provided as the signaling device for staff assistance. At approximately 9:30 a.m., two licensing inspectors were on one of the two units on the 3rd floor and did not observe the presence of any staff. At approximately 9:35 a.m., the hand bell for Resident #9 was rung; however, 10 minutes past and no staff were observed on the unit to respond. At approximately 9:49 a.m., on the other unit on the third floor, the hand bell for Resident #10 was rung; however, 10 minutes past and no staff were observed on the unit to respond. From approximately 9:30 a.m. to 10:00 a.m., there was not a staff member present on the third floor.
Plan of Correction:	The call bell system was under repair and a part for the call bell was on back order. The Administrator informed the licensing inspector prior to survey of the repairs and backorder of the part. The Administrator reviewed with the inspector the use of handbells and increased rounding. The Administrator also informed the inspector that each resident in assisted living was educated on the use of handbells. The education was documented in each residents? medical chart. The inspector approved the use of handbells. Each resident was issued 2 handbells. One for their room and one for their restroom. Each week rounds were made by a Department Heads to ensure that residents still had handbells. Rounds were documented on a rounding sheet. A R.MA. and C.N.A. were assigned to the 3rd floor. There were no adverse effects on the residents. The part arrived and Simplex repaired the system on May 27, 2022. The call bell system is fully functional.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have completed criminal history record reports on or prior to the 30th day of employment: Staff #6 (hired 02/07/2022 ? report completed 03/16/2022), Staff #7 (hired 02/21/2022 ? report completed 04/20/2022), Staff #8 (hired 03/21/2022 ? report completed 04/25/2022), and Staff #9 (hired 03/02/2022 ? report completed 04/20/2022).
Plan of Correction:	All current staff have obtained a criminal history record report prior to their 30th day of employment. There were no adverse effects on the residents. The Business Office Manager was in-serviced on criminal background checks. An audit sheet was created for new hires to ensure that a criminal history record was obtained prior to their 30th day of employment. If a report was not obtained prior to 30 days, then the new hire will be removed from the scheduled until the criminal history is obtained and reviewed. The Administrator will complete an audit of all new hires weekly for 3 months to ensure that a criminal history is obtained prior to the 30th day of employment. The results of the audit will be presented to QAPI Committee for review or recommendations.