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: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

22VAC40-73-890

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: 1/18/2024 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. Five complaints were received by VDSS Division of Licensing on 12/29/2023, 1/2/2024, 1/13/2024 (2), and 1/16/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, Buildings and Grounds, and Emergency Preparedness. 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: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 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: Administration and Administrative Services, Buildings and Grounds, and Emergency Preparedness. A violation notice was issued; any violation(s) not related to the complaints 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident #6 passed away unexpectedly on 1/16/2024. An incident report was not submitted to the regional licensing office within 24 hours of this incident. 2. Staff #1 acknowledged the facility did not make a report regarding this incident to the regional licensing office.
Plan of Correction:	Facility delayed in reporting major incident due to holding internal investigation to properly report details. In the future, the facility will send a brief notification with a follow-up once the investigation is completed.
Standard #:	22VAC40-73-250-A
Complaint related:	No
Description:	Based on interview, the facility failed to ensure a record be established for each staff person. Evidence: 1. Staff #1 was unable to provide a staff record for Staff #2 (hired 1/12/2024).
Plan of Correction:	Daily reviews will be conducted to ensure staff records are completed.
Standard #:	22VAC40-73-610-B
Complaint related:	No
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. On 1/18/2024, the posted menu on the 1st floor, 3rd floor, and memory care was for the week of 1/7/2024-1/13/2024.
Plan of Correction:	The facility has hired a new Dietary Manager who will ensure that menus are posted in all appropriate areas in a timely manner.
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 peephole to Resident #1?s apartment was missing which allowed viewers to look inside the apartment from their door. 2. A hole was noted to the roof above the covered patio. The hole extended into the covered patio. 3. The smoke detector in Resident #2?s apartment was noted to be hanging from the ceiling. 4. The smoke detector in Resident #3?s apartment was missing and showed exposed wires above the resident?s bed.
Plan of Correction:	Maintenance Director to personally inspect each room Monday through Friday for any needed repairs. Maintenance to complete maintenance repairs in a timely manner.
Standard #:	22VAC40-73-950-E
Complaint related:	Yes
Description:	Based on interview, the facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers with emphasis placed on an individual's respective responsibilities. Evidence: 1. Staff #1 could not provide documentation that for all staff, residents, and volunteers receive a semi-annual review on the emergency preparedness and response plan.
Plan of Correction:	Not available online. Contact Inspector for more information.