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: Jan. 18, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

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: 01/18/2024 from 10:45 am to 1:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/10/2024 regarding allegations in the area(s) of: Building 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Room temperatures were taken in resident apartments and common areas throughout the facility. 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 #:	22VAC40-73-880-B
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 Staff #1 and the facility?s movable thermometer on 01/18/2024, 15 apartments throughout the facility were measured and were below 72?F. The 15 apartments measured were occupied and ranged from 57.9?F to 71?F. Common areas and dining rooms were also measured throughout the facility with some areas noted below 72?F.
Plan of Correction:	Facility self-reported to DSS service failure on HVAC system. Mid-Atlantic Heating and Cooling were immediately notified and began working to repair heat pump. Work was not completed until 1/19/2024 due to delivery dates with Mid Atlantic Heating and Cooling. Residents and family members affected by service failure were notified and Karolwood Gardens offered to move residents to non-affected model rooms. Residents and families declined and chose to stay in their rooms. Activities were increased in common areas without service failures. Karolwood continues to be on continuance service plans with Mid Atlantic Heating and Cooling as well as Trane Heating and Cooling.
Standard #:	22VAC40-73-950-A
Description:	Based on record review and discussion, the facility failed to develop a written emergency preparedness plan to include an analysis of the facility's potential hazards, including loss of utilities or other emergencies that would disrupt normal operation of the facility. Evidence: 1. Staff #1 was unable to provide the facility?s emergency preparedness and response plan to address the loss of heat due to emergency situations or malfunctioning or broken equipment and what actions the facility would take to protect the residents.
Plan of Correction:	Executive Director created updated Emergency Preparedness and Response Plan. In-Service training was completed with all staff on 1/23/2024. In-services will be conducted every January and June in each calendar year to ensure all staff as comfortable and ready in Emergency Preparedness and Response times. Additionally, all new hires have completed this training on first day of employment and will continue to do so going forward.