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: Oct. 2, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/02/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Six complaints were received by VDSS Division of Licensing on from 09/21/2023 to 09/27/2023 regarding allegations in the area(s) of: Background Checks, Personnel, Admission, Retention and Discharge of Residents, Buildings and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairment. Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 63 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Additional Comments/Discussion: LI reviewed the background checks for all new hires since the renewal inspection (04/11/2023). An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Background Checks and Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-250-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure all staff records be treated confidentially. Evidence: 1. During the tour of the facility, unit 2115 is being utilized for record storage to include staff records. The confidential information contained within this unit is available to maintenance and housekeeping staff.
Plan of Correction:	1. Ensure proper record storage, place in a properly secured site, with Administrator having the only key for access.
Standard #:	22VAC40-73-280-E
Complaint related:	No
Description:	Based on record review, the facility failed to ensure no employee be permitted to work in a position that involves direct contact with a resident until a background check has been received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such person works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90). Evidence: 1. Per the September 2023 staff schedule, Staff #13 worked 11 shifts and Staff #17 worked 5 shifts between 09/01/2023-09/29/2023 as a direct care staff. Staff #1 was unable to provide documentation or evidence that Staff #13 (hired 07/19/2023) and Staff #17 (hired 08/29/2023) worked under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90) prior to the receipt of the background check for Staff #13 (completed 09/29/2023) and Staff #17 (completed 09/29/2023).
Plan of Correction:	1. Ensure proper record keeping for staff schedules.
Standard #:	22VAC40-73-560-F
Complaint related:	No
Description:	Based on observation, the facility failed to ensure all resident records are treated confidentially and that information shall be made available only when needed for care of the resident. Evidence: 1. During the tour of the facility, unit 2115 is being utilized for record storage to include resident records. The confidential information contained within this unit is available to maintenance and housekeeping staff.
Plan of Correction:	1. Ensure proper record storage, place in a properly secured site, with Administrator having the only key for access.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. The bathroom of Resident #1 contained several stained ceiling tiles with one directly above the shower with a light. 2. The bathroom of Resident #2 contained missing ceiling tiles exposing pipes and ductwork. 3. The Colony Point section of the second floor (ten units) remains closed at this time due to repairs; however, the section was accessible and unlocked at the time of inspection with noted hazards to include exposed ceilings, electrical closet with breaker box open, and hanging wires. 4. The kitchenette of Ghent section of the second floor was noted to have a white, black, and grey substance on the ice/water machine.
Plan of Correction:	1. Ensure unit under construction is properly labeled. 2. Ensure ceiling tiles are inspected during morning rounds to ensure replacements are completed immediately. 3. Ensure ceiling tiles are inspected during morning rounds to ensure replacements are completed immediately. 4. Ensure unit under construction is properly labeled. 5. Ensure unit under construction is properly labeled.
Standard #:	22VAC40-90-40-B
Complaint related:	No
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 a criminal history record report completed on or prior to the 30th day of employment: Staff #2 (hired 06/06/2023) completed 07/17/2023, Staff #3 (hired 07/06/2023) completed 08/22/2023, Staff #4 (hired 06/09/2023) completed on 08/22/2023, Staff #5 (hired 05/26/2023) completed 08/22/2023, Staff #6 (hired 07/19/2023) completed 08/22/2023, Staff #7 (hired 06/26/2023) completed 08/22/2023, Staff #8 (hired 07/20/2023) completed on 08/25/2023, Staff #9 (hired 05/30/2023) completed 07/27/2023, Staff #10 (hired 06/04/2023) completed 07/27/2023, Staff #11 (hired 06/08/2023) completed 07/27/2023, Staff #12 (hired 08/03/2023) not completed at the time of inspection on 10/02/2023, Staff #13 (hired 07/19/2023) completed 09/29/2023, Staff #14 (hired 06/20/2023) completed 08/25/2023, and Staff #15 (hired 06/20/2023) completed 07/27/2023.
Plan of Correction:	1. Ensure Human Resource Officer obtains criminal background on or before start of employment.
Standard #:	22VAC40-90-40-H
Complaint related:	Yes
Description:	Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes. Evidence: 1. Staff #16 was hired on 08/25/2023. A criminal history record report for Staff #16 was completed on 08/30/2023. The criminal history record report indicates Staff #16 was convicted of a felony barrier crime.
Plan of Correction:	1. Ensure persons employed do not have a conviction of any barrier.