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. 26, 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

Technical Assistance:

22VAC40-73-450 22VAC40-73-870 22VAC40-73-1110

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: 10/26/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/18/2023 regarding allegations in the area(s) of: Background Checks, Personnel, Admission, Retention and Discharge of Residents, Resident Care and Related Services, 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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: Personnel and Resident Care and Related Services. 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 #:	22VAC40-73-220-A
Complaint related:	Yes
Description:	Based on interview, the facility failed to provide or obtain required information in the record for private duty personnel. Evidence: 1. Resident #6 utilizes private duty personnel. The facility was unable to provide in writing information on the type and frequency of the services to be delivered to the resident by private duty personnel, verification the private duty personnel adhere to the requirements of 22VAC40-73-250 D 1 through D 4 regarding tuberculosis, and verify that the private duty personnel received orientation and training regarding the facility's policies and procedures related to the duties of private duty personnel.
Plan of Correction:	Policy and procedures enacted for private duty personnel. Maintain designated binder for private duty personnel to include VSP BCB, TB Screening, and Staff Orientation.
Standard #:	22VAC40-73-440-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI. Evidence: 1. The UAIs for Resident #5 (dated 09/28/2023) and Resident #6 (dated 10/4/2023) were not approved and signed by the administrator or the administrator?s designated representative.
Plan of Correction:	All UAIs for Residents are to be verified by the Inspector, Administrator, and Office Manager to ensure all signatures are obtained and forms are completed accurately.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the resident or their legal representative. Evidence: 1. The ISPs for Resident #4 (dated 10/13/2023), Resident #5 (dated 10/6/2023), and Resident #6 (dated 10/4/2023) were not signed and dated by the resident or their legal representative.
Plan of Correction:	Ensure all individualized service plans conducted over phone meetings are signed and returned by responsible participants. Obtain copies of email correspondences to verify ISP forms are sent to responsible participants.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The following medications were not documented as administered on the October MAR for Resident #1: 9:00 am dose of Furosemide 20mg tab on 10/14/23 and 10/15/23, 9:00 am dose of multivitamin on 10/14/23 and 10/15/23, 9:00 am dose of Venlafaxine 150 mg tab on 10/14/23 and 10/15/23, and 9:00 am dose of Xarelto 20 mg tab on 10/14/23 and 10/15/23. 2. The following medications were not documented as administered on the October MAR for Resident #2: Aspirin 81 mg tab on 10/2/23, 10/3/23, and 10/14/23, Duloxetine 30 mg tab on 10/2/23, 10/3/23, and 10/14/23, Nifedipine 30 mg tab on 10/2/23, 10/3/23, and 10/14/23, Metoprolol 50 mg tab on 10/2/23, 10/3/23, and 10/14/23, Valsartan 320 mg tab on 10/2/23, 10/3/23, and 10/14/23, Vitamin D 10000 unit tab on 10/2/23, 10/3/23, and 10/14/23, Multivitamin tab on 10/2/23, 10/3/23, and 10/14/23, Buspirone 5mg tab on 10/2/23, 20/3/23, 10/6/23, 10/12/23, 10/14/23, 10/16/23, 10/16,23, 10/19/23, 10/21/23, and 10/22/283, Tylenol 650 mg tab on 10/14/23-10/22/23, 10/24/23, and 10/25/23, Augmentin 875-125 mg tab on 10/21/23-10/16/23. 3. The following medications were not documented as administered on the October MAR for Resident #3: Lacosamide 100 mg tab 9:00 am dose on 10/2/23 and 10/14/23 and 9:00 pm dose on 10/2/23, 10/3/23, 10/6/23, and 10/16/23. 4. The following medications were not documented as administered on the October MAR for Resident #4: Aquaphor topical cream on 10/19/23 and Coreg 6.25 mg tab on 10/19/23.
Plan of Correction:	Facility to implement eMAR effective 11/28/2023 to ensure all medications are properly documented with time stamp and signature of administrator. Daily audits to be conducted until this time to ensure paper MAR is accurate.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the MAR include the items required in the standard. Evidence: 1. The MARs for Resident #1, Resident #2, Resident #3, and Resident #4 did not the name, signature, and initials of all staff administering their medications. Staff #1 was unable to provide a master list in lieu of this documentation on individual MARs. 2. The MARs for Resident #1, Resident #2, and Resident #4 did not include the date their medications were prescribed.
Plan of Correction:	Facility to implement eMAR effective 11/28/2023 to ensure all medications are properly documented with time stamp and signature of administrator. Daily audits to be conducted until this time to ensure paper MAR is accurate.
Standard #:	22VAC40-90-40-H
Complaint related:	No
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 #2 was hired on 08/03/2023. A criminal history record report for Staff #2 was completed on 10/11/2023. The criminal history record report indicates Staff #2 was convicted of a misdemeanor barrier crime in 2021.
Plan of Correction:	Administrator, HR, and Office Manger to have three-point check to verify all new hires are not placed on schedule until completed VSP CBC completed and received.