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: April 11, 2023 and April 13, 2023

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

Technical Assistance:

22VAC40-73-440 22VAC40-73-890 22VAC40-73-990 22VAC40-73-930

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: 04/11/2023 from 8:40 am to 4:10 pm and 04/13/2023 from 8:45 am to 11:45 am. 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 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 #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents are 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. The serious cognitive assessments for Resident #1 (dated 10/17/22) and Resident #8 (dated 5/1/22) indicate the resident is able to recognize danger or protect their own safety and welfare.
Plan of Correction:	1. Resident #1?s cognitive assessment was corrected. 2. Administrative staff was in-serviced on 22VAC40-73-1090-A. 3. A 100% audit was completed on current Special Care residents? cognitive assessments to ensure compliance. 4. Administrator/Designee will monitor cognitive assessments to ensure compliance. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-210-G
Description:	Based on record review, the facility failed to ensure there is documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: 1. The records for Staff #3 and Staff #4 indicate both staff completed 16 hours of annual in-services; however, the documentation did not include the dates the types of training were individually completed.
Plan of Correction:	1. Staff #3 and Staff #4?s documentation was updated to indicate dates of training instead of total training hours and completion date. 2. Administrative Staff were in-serviced on 22VAC40-73-210-G to include documentation of each training. 3. Staff training records will be updated and maintained on RECORD OF STAFF TRAINING AND EDUCATION FOLLOWING EMPLOYMENT VDSS Model Form-ALF 032-05?0529-02-eng (02/18). 4. Administrator/Designee will monitor training and ensure it is documented on the Record of Staff Training and Education Following Employment. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form 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. The TB risk assessment for Staff #2 (hired 1/13/23) was not dated or completed.
Plan of Correction:	1. The TB risk assessment was completed and dated for staff member #2. 2. LPNs were in-serviced on 22VAC40-73-250-D. 3. All current staff records will be reviewed to ensure TB risk assessments were completed and dated. 4. Administrator/Designee will monitor TB risk assessments for completion. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #2 (hire date 1/13/23) works as direct care staff and does not have documentation of a current certification in first aid in their staff record. 2. Staff #1 confirmed Staff #2 does not have a current certification in first aid in their staff record.
Plan of Correction:	1. Staff #2 obtained first aid certification. 2. Administrative staff were in-serviced on 22VAC-40-73-260-A 3. All current staff records will be reviewed to ensure that direct care staff members have current certification in First Aid and CPR. 4. Administrator/Designee will monitor staff records to ensure direct care staff have current certification in First Aid and CPR.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 4/11/23, the posted staffing assignment indicated Staff #1 was the designated on-site person in charge; however, Staff #1 was not on-site at the facility at that time.
Plan of Correction:	1. Staff #1 was at a scheduled M.D. appointment while on her 30-minute break. It does not state in the Standard that there should be two people as the on-site person in charge to accommodate breaks. 2. Administrative staff were in-serviced on 22VAC40-73-290-B with the adage to have 2 designated people as on-site person in charge to accommodate required 30 minute break. 3. Administrator/Designee will monitor posted on-site person in charge to reflect to adage of 2 designate people as on-site person in charge to accommodate required 30-minute break.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to annually 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. The last TB risk assessment for Resident #6 was completed on 3/25/2022.
Plan of Correction:	1. Resident #6?s TB assessment was completed. 2. A in-service was completed with administrative staff regarding 22VAC40-73-320-B. 3. A 100% audit of current residents will be completed of TB assessments to ensure timely completeness. 4. Administrator/Designee will monitor TB assessments for completeness. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete a resident?s UAI at least annually. Evidence: 1. The last UAI for Resident #3 was completed on 3/27/2022.
Plan of Correction:	1. Resident #3 was completed. 2. Administrative staff was in-serviced on 22VAC40-73-440-A 3. A 100% audit will be completed on all current residents UAI to ensure compliance. 4. Administrator/Designee will monitor UAIs are complaint. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. Resident #6 admitted to the facility on 4/25/2022; however, the ISP for Resident #6 was completed on 4/30/2022. 2. Resident #7 admitted to the facility on 10/7/2022; however, the ISP on record for Resident #7 was dated 12/1/2022. There was no preliminary plan of care or ISP on or within seven days prior to the day of admission in Resident #7?s record.
Plan of Correction:	1. A preliminary ISP was completed for Resident # 6 and Resident #7. 2. Administrative staff was in-serviced on 22VAC40-73-450-A. 3. A 100% audit will be completed on preliminary plan of care for current residents. 4. Administrator/Designee will monitor new admission to ensure preliminary plan of care are completed on or within seven days prior to the day of admission. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs based upon the UAI. Evidence: 1. Resident #1?s UAI (dated 10/14/2022) indicates the resident does not require assistance with dressing, toileting, and mobility; however, Resident #1?s ISP (dated 10/19/2022) indicates the resident requires physical assistance as needed and assistance with buttons and zippers with dressing and supervision with toileting and mobility. 2. Resident #2?s UAI (dated 12/1/2022) indicates the resident requires mechanical and physical assistance with bathing, mechanical assistance with toileting, transferring and walking, and bladder incontinence less than weekly; however, Resident #2?s ISP (dated 12/1/2022) does not indicate the type of assistance the resident requires for bathing and does not address the resident?s assistance need for toileting, transferring, walking, or bladder incontinence. 3. Resident #3?s UAI (dated 3/27/2022) indicates the resident does not require assistance with bathing, dressing, toileting, eating/feeding, bowel incontinence, and mobility; however, Resident #3?s ISP (dated 3/27/2022) indicates the resident requires supervision and physical assistance as needed with bathing and dressing, supervision with toileting, eating/feeding and mobility, and indicates the resident is incontinent of bowel. 4. Resident #4?s UAI (dated 3/28/2023) indicates the resident requires mechanical assistance with stairclimbing and no assistance with mobility; however, Resident #4?s ISP (dated 4/3/2023) does not address the resident?s need with stairclimbing and indicates the resident requires mechanical and supervision assistance with mobility. 5. Resident #6?s UAI (dated 4/28/2022) indicates the resident does not require assistance with bathing and mobility; however, Resident #6?s ISP (dated 4/30/2022) indicates the resident requires reminders and physical assistance as needed with bathing and supervision with mobility. Additionally, the ISP does not include a date identified for the need of assistance with money management. 6. Resident #8?s UAI (dated 4/3/2023) indicates the resident does not require assistance with bathing, dressing, toileting, walking and mobility and states the resident self-administers medications, has appropriate behavior, and is oriented; however, Resident #8?s ISP (dated 6/14/2022) indicates the resident requires reminders and physical assistance as needed with bathing, supervision and physical assistance as needed with dressing, supervision with toileting, walking, and mobility, and that staff administer the resident?s medications. The ISP also indicates the resident resides in the safe, secure environment due to serious cognitive impairment related to dementia and at risk for elopement or unsafe wandering. It also indicates the resident wanders, refuses treatment, takes others? possessions, exit seeks, and is verbally abusive in relation to their behavioral symptoms.
Plan of Correction:	1. Resident #1, #2, #3, #4, and #6 UAI and ISP was updated, 2. Administrative staff was in-serviced on 22VAC-40-73-450-C. 3. A 100% audit will be completed on UAI and ISPs on current residents to ensure compliance. 4. Administrator/Designee will monitor UAIs and ISPs to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs based upon the UAI. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans be reviewed and updated at least once every 12 months. Evidence: 1. The last ISP for Resident #3 was completed on 3/27/2022.
Plan of Correction:	1. Resident #3?s ISP was updated. 2. Administrative staff was in-serviced on 22VAC40-73-450-F. 3. A 100% audit will be completed on all ISP?s on current residents to ensure compliance. 4. Administrator/Designee will monitor ISPs to ensure individualized service plans be reviewed and updated at least every 12 months. Any trends will be reported to QAPI.
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 on 4/11/2023, two residents were observed in one of the dining rooms on the third floor of the assisted living eating breakfast around 8:35 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:	1. On 4/11/2023 a staff member was in the dining room at 8:35 a.m. 2. Administrative staff was in-serviced on 22VAC40-73-450-F 3. A written agreement will be signed for residents wishing to eat in their rooms and their ISPs will be updated as indicated. 4. Administrator/Designee will monitor dining rooms and written agreement to ensure compliance. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During the tour of the facility on 4/11/2023, the menus posted indicate the meals for Monday, Tuesday, and Wednesday; however, the menus did not include the date or show the meals for the current week.
Plan of Correction:	1. The menus are posted on each floor and Special Care. The menus state the current day of the week. The menus did not have the month/day/year and was immediately corrected. 2. Administrative staff was in-serviced on 22VAC40-73-610-B. 3. The menus were updated to include month/day/year. 4. Administrator/Designee will monitor menus to ensure that they include month/day/year not just the day of week. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: a bottle of hydroxyzine pamoate 25mg capsules expired 11/18/22 for Resident #9.
Plan of Correction:	1. Resident #9?s expired medication was reviewed from the med cart. 2. LPNs/RMAs will be in-serviced on 22VAC40-73-640-A. 3. Medication Carts were audited to ensure that any expired medications were removed from the medication cart. 4. Administrator/Designee will monitor medication carts to ensure they are free of expired medications. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-680-G
Description:	Based on record review, the facility failed to ensure over-the-counter medication should remain in the original container, labeled with the resident's name, or in a pharmacy-issued container, until administered. Evidence: 1. The following medications were observed on the medication carts in assisted living without a label with the resident?s name: a bottle of Vitamin C 500mg tablets, 2 bottles of Omeprazole 20 mg capsules, a bottle of Thera M-Multivitamin caplets, a bottle of Mickeys Fine Malt Liquor, a bottle of Centrum Silver tablets, a bottle of Spring Valley Vitamin D3 soft gels, a bottle of Calcium 600 mg tablets, a bottle of Preservision soft gels, a bottle of Equate 8hr Arthritis tablets, a bottle of Tylenol caplets, and a bottle of Nutrilite Heart Health Omega soft gels.
Plan of Correction:	1. Over-the-counter medications are in the original container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. 2. LPNs and RMAs will be in-serviced on 22VAC40-73-680-G. 3. Medication Carts were audited to ensure that OTCs were in the original container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. 4. Administrator/Designee will monitor medication carts to ensure OTCs were in the original container labeled with the resident?s name or in a pharmacy issued container, until administered. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Resident #1?s ISP (dated 10/19/2022) and last Physician Order Sheet indicates the resident as a DNR; however, their record did not contain a copy of their DNR. 2. Resident #3 has a DNR order (dated 5/5/22); however, their ISP (dated 3/27/22) indicates the resident as a Full Code. 3. Resident #8?s Resident Personal/Social Data Form indicates the resident as a DNR; however, the resident?s Physician Order Sheet and ISP (dated 6/14/22) indicates the resident as a Full Code.
Plan of Correction:	1. Resident #1, #3 and Resident #8 code status was updated. 2. Administrative staff, LPNs, RMAs, CNAs and PCAs will be in-serviced on 22VAC40-73-720-A. 3. 100% of current residents? Code Status was audited for compliance. 4. Administrator/Designee will monitor code statuses to ensure compliance. Any trends will be reported to QAPI.
Standard #:	22VAC40-73-860-G
Description:	Based on observation, the facility failed to ensure hot water at taps available to residents be maintained within a range of 105?F to 120?F. Evidence: 1. During a tour of the facility on 4/11/23, the hot water taps sampled were not within the required range in the following areas: common area bathroom off the lobby measured 131?F and kitchen sink of Resident #10 measured 128?F. 2. During a tour of the facility on 4/13/23, two bathroom sinks in apartments within the safe, secure environment were measured at 127?F and 128?F.
Plan of Correction:	1. Administration reported to the surveyor that they were aware of the issue. While taking water temperatures it was determined there was an issue. A plumber was immediately called. The plumber determined that a new mixing valve was needed and ordered the part. Staff and residents were immediately notified of the issue. 2. Administrative staff was in-serviced on 22VAC40-73-860-G.
Standard #:	22VAC40-73-940-A
Description:	Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 03/24/2022.
Plan of Correction:	1. Administrator informed inspector that she tried on numerous occasions to contact the Fire Marshall. Administrator left messages without a return call. Inspector gave administrator another contact name. The Fire Marshall was out of leave for the past two months. Another Fire Inspector completed annual Inspection on 4/18/2023.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #6 was hired on 8/23/2022; however, the criminal history record report was obtained on 11/30/2022.
Plan of Correction:	1. Staff #6 has a valid criminal history report and is compliant. 2. Administrative staff were in-serviced on 22VAC40-90-40-B. 3. A 100% audit will be completed on all current staff and agency staff for compliance. 4. Administrator/Designee will monitor criminal history checks including agency to ensure that criminal history checks are obtained on or prior to the 30th day of employment. Any trends will be reported to QAPI.
Standard #:	22VAC40-90-50-A
Description:	Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency contain information listed in the standard. Evidence: 1. The records of Staff #5 indicate the background checks is not completed by the Virginia State Police.
Plan of Correction:	1. Staff #6 had a clean criminal history check from a reputable company. It was not obtained from the Virginia State Police. 2. Administrative Staff and Current Agency Companies were in-serviced on 22VAC40-90-40-B. 3. A 100% audit will be completed on current staff and agency staff for compliance. 4. Administrator/Designee will monitor criminal history checks including agency to ensure that criminal history checks were completed by Virginia State Police. Any trends will be reported to QAPI.