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: Feb. 21, 2024 and Feb. 28, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Technical Assistance:

22VAC40-73-580 22VAC40-73-870

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: 02/21/2024 from 11:25 am to 1:10 pm and 02/28/2024 from 12:15 pm to 1:33 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Eight complaints were received by VDSS Division of Licensing on 02/13/2024, 02/16/2024, 02/20/2024, 02/22/2024 (4), and 02/28/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, Resident Care and Related Services, and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 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, 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 #:	22VAC40-73-150-F
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure an administrator serve on a full-time basis as the on-site agent of the licensee and be responsible for the day-to-day administration and management of the facility. Evidence: 1. From 01/13/2024 to 02/20/2024, the facility did not employ an administrator on a full-time basis as the onsite agent of the licensee.
Plan of Correction:	A full-time administrator was employed effective 2/21/2024. Facility will ensure to maintain a licensed administrator on a full-time basis in the future. Department of Social Services will be notified of any changes in administrator of record as soon as practicable.
Standard #:	22VAC40-73-200-C
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure direct care staff meet one of the requirements in this subsection. Evidence: 1. Staff #3 works at the facility and was hired on 2/21/2022 as direct care staff; however, their record only includes an expired CNA license as of 11/30/2022.
Plan of Correction:	Staff #3 reapplied for the reinstatement of an expired CNA license on 3/1/2024. Staff #3 is not performing any resident care in the meantime. The facility will ensure that all RMAs either have an active CNA/PCA license or sign a job description limited to medication administration duties. A complete audit of all RMA employee files will be performed to identify individuals unqualified to perform resident care. Job descriptions will be updated as necessary. Facility Administrator or designee will perform periodic audits of all RMA records to ensure future compliance.
Standard #:	22VAC40-73-610-B
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure snacks for the current week be dated and posted in an area conspicuous to residents. Evidence: 1. On 02/28/2024, the snack list posted throughout the facility was not dated nor current with the snacks available. The following items were listed and were not available: assorted cookies, yogurt, trail mix, chex mix, and granola bars.
Plan of Correction:	Snack lists have been updated to reflect in-house snacks available. Director of Dining Services or designee will oversee that the snack lists are kept up to date in the future. Administrator or designee will periodically request snacks from the posted snack list to ensure their availability.
Standard #:	22VAC40-73-660-A-1
Complaint related:	No
Description:	Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration shall keep the keys to the storage area on their person. Evidence: 1. At approximately 11:35 am on 02/21/2024, the top drawer of one of the medication carts on the first floor in the assisted living was observed to be unlocked and unattended.
Plan of Correction:	A in-service for all registered staff was conducted to remind licensed staff to lock the carts on 3/6/2024. Administrator or designee will periodically check the carts for compliance.
Standard #:	22VAC40-73-670-3
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure medication aides are supervised by one of the following individuals listed in the standard. Evidence: 1. As of 01/29/2024, the facility does not employ a qualified individual to supervise medication aides.
Plan of Correction:	Facility is in the process of recruiting an LPN. Facility will ensure a qualified individual to supervise medication aides at all times is employed in the future.
Standard #:	22VAC40-73-680-C
Complaint related:	No
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 February 2024 MAR indicates Resident #1 did not receive their Haloperidol injection on 02/13/2024 as the facility did not have qualified staff to administer the medication. The February 2024 MAR also indicated Resident #1 missed one dose of Benztropine 1mg tablet on 02/15/2024 and Vitamin D 50000-unit capsule on 02/06/2024 and 02/13/2024.
Plan of Correction:	The facility is in the process of recruiting an LPN. Facility will ensure a qualified individual to administer injections will be available in the future. LPN will perform eMAR audits to address any missed medications.
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. A hole was noted to the roof above the covered patio. The hole extended into the covered patio. 2. The smoke detector in Resident #3?s apartment was noted to be hanging from the ceiling.
Plan of Correction:	A hole in the roof has been repaired on 3/5/2024. The smoke detector in resident #3?s apartment has been repaired.
Standard #:	22VAC40-73-930-A
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure all assisted living facilities have a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance. Evidence: 1. On 02/28/2024, Resident #2 was not observed to have an operable signaling device available to alert direct care staff for assistance. Resident #2 indicated they fell on early morning of 02/26/2024 and were on the floor from 12 am to 9 am. 2. Staff and private duty confirmed the resident was found on the floor around 9 am and did not have an operable signaling device available at the time of the incident.
Plan of Correction:	Resident #2 was given a signaling device the day of the inspection on 2/28/2024. A full audit of all residents has been completed to ensure all residents have a call bell pendant. A periodic audit will be conducted by Administrator or designee to ensure compliance.