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: July 14, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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

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: 07/14/2022 from 8:55 am to 11:50 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three self-reported incidents were received by VDSS Division of Licensing on 6/15/2022, 6/21/2022, and 6/24/2022 regarding allegations in the area(s) of: Staffing and Supervision, Admission, Retention and Discharge of Residents, Resident Care and Related Services, Emergency Preparedness, and Additional Requirements for Facilities that care for adult with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Additional Comments/Discussion: All exit doors/points of the safe, secure environment secured. 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 #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Staff #1 and Staff #2 stated Resident #1 transferred into the special care unit on 5/12/22; however, the assessment of serious cognitive impairment was not completed until 5/20/22.
Plan of Correction:	Resident #1 assessment of serious cognitive impairment was completed on 5/20/2022. There is no adverse effect to this resident. All other residents in the Special Care Unit have the appropriate documents. Administrator or designee will review each resident on special care unit every 6 month for appropriate continuous placement. The resident of review will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-1100-A
Description:	Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. Evidence: 1. Staff #1 and Staff #2 stated Resident #1 admitted into the special care unit on 5/12/22. The documentation of approval for placement in a special care unit for Resident #1 indicates approval via call was obtained on 5/12/22; however, the POA did not provide written approval until 5/19/22. 2. Resident #2 did not have documentation of approval for placement in a special care unit in the resident record.
Plan of Correction:	Resident #1 approval was completed verbally of 5/12/2022. The POA was working night shift and unable to sign. The POA provided written approval on his next day off on 5/19/2022. Resident #2?s approval was completed. There is no adverse effect to Resident #1 or Resident #2. All other residents in the Special Care Unit have the appropriate documents. Administrator or designee will review resident pre-admission document to assure that appropriate documentation for special care unit is in place. The results of review will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #1 and Resident #2 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	The documentation of the determination and justification on whether placement in the Special Care Unit is appropriate for Resident #1 and Resident #2 by the Administrator was placed in Resident #1 and Resident #2?s admission records. Administrator will audit all residents in the Special Care Unit to assure each resident has the documentation of the determination and justification on whether placement in the Special Care Unit is appropriated in their admission records. Administrator or designee will review resident pre-admission document to assure that appropriate documentation for Special Care Unit is in place. Administrator or designee will review each resident on special care unit every 6 month for appropriate continuous placement. The results of review will be presented to facility QAPI committee for review or recommendations.
Standard #:	22VAC40-73-1150-A
Description:	Based on observation, record review 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 6/15/22 around 11:10 a.m., Resident #1 who resides in a safe, secure environment was unable to be located. The resident was last seen around 10:30 a.m. as noted by staff. The June MAR for Resident #1 indicates ?check wanderguard placement q shift for elopement risk.? During this time on the day of the incident, the facility was on Fire Watch and alarms were sounding due to repairs on the fire system. The incident report submitted on 06/15/2022 indicates staff did not hear the alarm. Resident #1 was located .3 miles away at approximately 11:40 a.m.
Plan of Correction:	Resident #1 was last seen at 10:30 a.m. Staff were unable to locate Resident #1 at 11:10 a.m. for an activity. Resident Care Coordinator was immediately notified. Per policy for Handling a Missing Resident: RCC notified the Administrator. The Administrator notified all staff on duty. Staff searched the building, made a room-to-room check, in all communities: opening all doors including closets and bathrooms. Administrator directed staff from each department to make rounds of the exterior of the building and search the parking lots and areas on the property. All common areas, lobbies, halls, stairwells, and utility areas were checked. During this time alarms were sounding due to repairs on the fire system. It is believed Resident #1 exited and staff did not hear the alarm. 11:25 a.m. The Police and Responsible Party was notified. Voicemail was left for Responsible Party. 11:41 a.m. Resident was found. There is no adverse effect to this resident. A 2nd alarm will be placed on each exit door in the Special Care Unit as back up to the main system. The PA-C evaluated resident after the incident. Resident had no adverse effects. A new elopement risk assessment was completed. The ISP was updated to reflect any changes. Staff are aware if the fire alarm sounds that a staff member must monitor the fire exit doors.