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: Dec. 14, 2023

Complaint Related: Yes

Areas Reviewed:

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

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: 12/14/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three complaints were received by VDSS Division of Licensing on 12/05/2023, 12/06/2023, and 12/09/2023 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 54 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 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 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: Resident Care and Related Services 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 #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review, the facility failed ensure resident?s comprehensive individualized service plan include a description of identified needs. Evidence: 1. Resident #2?s UAI (dated 06/08/2023) indicates the resident requires physical assistance with dressing, mechanical and physical assistance with mobility, and assistance with meal preparation, housekeeping, and laundry; however, Resident #2?s ISP (dated 09/01/2023) indicates the resident does not require assistance with dressing, meal preparation, housekeeping, and laundry and requires only mechanical assistance with mobility. Resident #2?s ISP also does not address their special diet of no added salt and no concentrated sweets.
Plan of Correction:	RCC and Executive Director to meet weekly to review UAI and ISP, ensuring resident care and needs are met accordingly. UAI, ISP, and Physician Orders will be verified, and corrections made to ensure appropriate measures are met.
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 #3 (dated 12/08/2023) were not signed and dated by the resident or their legal representative.
Plan of Correction:	RCC and Executive Director to meet weekly to review UAI and ISP, ensuring resident and/responsible party has successfully signed all necessary documents.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure the individualized service plans be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #1 was admitted to hospice services on 09/08/2023 and discharged from hospice on 12/01/2023; however, their ISP dated 12/01/2022 was not updated to reflect either significant change.
Plan of Correction:	RCC and Executive Director to meet weekly to review UAI and ISP, ensuring resident care and needs are met accordingly. UAI, ISP, and Physician Orders will be verified, and corrections made to ensure appropriate measures are met. Meetings will be held with Resident, Responsible Party, RCC, Hospice Provider, Home Health Provider, and Physician to place accuracy on UAI and ISP.
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 December MAR for Resident #2: Budesonide on 12/10/23-12/11/23, Florastor 250 mg capsule on 12/9/23-12/14/23, Ipratro/Albuter 12/8/23-12/9/23, and Omeprazole 20 mg capsule on 12/1/23 and 12/4/23.
Plan of Correction:	The facility has switched to eMAR vs paper MAR to ensure accuracy with date, time, and dosages are met. RCC to meet with RMA?s weekly.
Standard #:	22VAC40-73-700-2
Complaint related:	No
Description:	Based on observation, the facility failed to post "No Smoking-Oxygen in Use" signs and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: 1. During a tour of the facility, Resident #4 was noted to have an oxygen concentrator in their apartment; however, there is not a ?No Smoking-Oxygen in Use? sign posted outside their apartment.
Plan of Correction:	Direct Care Staff inspect OXYGEN IN USE signs are visibly posted on the door to such resident?s room. Daily shift rounds will include inspection of proper signage.
Standard #:	22VAC40-73-700-5
Complaint related:	Yes
Description:	Based on interview, the facility failed to demonstrate that all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment. Evidence: 1. Staff #1 was unable to provide documentation of the facility demonstrating that all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment.
Plan of Correction:	RCC and Executive Direct to ensure all Direct Care Staff receive continued training or instruction in the use and maintenance of resident-specific equipment. Executive Director to review staff files weekly to ensure trainings are properly documented.
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 kitchenette of Ghent section of the second floor was noted to have a covered, inoperable ice/water machine with white, black, and grey substance on it as well as debris and substance on countertop surrounding the machine. 2. The bathroom within unit 2101 (unoccupied) which is accessible as it does not have a doorknob had exposed ceilings to include ductwork and stained ceiling tiles. 3. The bathroom vent above the shower in Unit 2109 and 2110 (both unoccupied) were not secured in the ceiling tile. 4. The bathroom for Resident #6 had stained ceiling tiles and only one light bulb (4 missing). The peephole to Resident #6?s apartment was also missing which allowed viewers to look inside the apartment from their door. 5. A hole was noted to the roof above the covered patio. The hole extended into the covered patio.
Plan of Correction:	Maintenance Department and Executive Director to ensure the interior of the building is maintained in good repair and kept clean and free of rubbish. Daily activity to include all Direct Care Staff round at start and finish of shift.
Standard #:	22VAC40-73-870-I
Complaint related:	No
Description:	Based on observation, the facility failed to ensure elevators, where used, be kept in good running condition, and be inspected at least annually. Elevators shall be inspected in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be evidence of such inspection. Evidence: 1. The certification of inspection for the elevator that is utilized by residents, visitors, and staff expired 03/31/2022.
Plan of Correction:	The elevator inspection was completed on 12/27/2023 after continuous calls to Elevator Inspector for over a year. Inspection Certificate is attached to this report.
Standard #:	22VAC40-73-880-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure heat be supplied from a central heating plant or an electrical heating system in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). A temperature of at least 72?F shall be maintained in all areas used by residents during hours when residents are normally awake. Evidence: 1. During a tour of the facility with the facility?s movable thermometer, Resident #5?s apartment measured 67?F. A thermostat was noted in the apartment; however, the resident is not able to control the temperature.
Plan of Correction:	The facility continues to work with Mid Atlantic Heating and Cooling as well as Trane to troubleshoot and repair/replace units as needed. Thermostat knobs are located in resident?s room.