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: April 10, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 04/10/2024 from 8:45 am to 4:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two complaints were received by VDSS Division of Licensing on 04/04/2024 and 04/09/2024 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services, 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: 52 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: 0 Number of interviews conducted with staff: 2 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 Additional requirements for Facilities that Care for Adults with Serious Cognitive Impairment. 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 #:	22VAC40-73-1120-F
Complaint related:	No
Description:	Based on interview, the facility failed to ensure the designated, qualified staff person responsible for managing or coordinating the structured activities program is on site in the special care unit at least 20 hours a week. Evidence: 1. Staff #3 is the designated, qualified staff person responsible for managing or coordinating the structured activities program in the special care unit; however, Staff #3 indicated they spend approximately 2 hours a day [10 hours per week] in the special care unit.
Plan of Correction:	The facility shall ensure Activities Coordinator is spending at least 20 hours per week in the special care unit. Per state regulations 22VAC40-73-1120-F, page 139: The required 20 hours on site does not have to be devoted solely to managing or coordinating activities; neither is it required that the person responsible for managing or coordinating the activities program conduct the activities.
Standard #:	22VAC40-73-150-A
Complaint related:	No
Description:	Based on interview, the facility fails to have an administrator of record. Evidence: 1. During the onsite inspection on 4/10/2024, Staff #1 was unable to provide an administrator of record for the facility.
Plan of Correction:	The facility shall provide an administrator of record for the facility. The facility will continue search for licensed administrator.
Standard #:	22VAC40-73-150-B-1
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure if an administrator resigns or is discharged, to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs. The facility failed to notify the department's regional licensing office in writing within 14 days of a change in a facility's administrator, including the resignation of an administrator, appointment of an acting administrator, and appointment of a new administrator. Evidence: 1. The regional licensing office was not notified upon discharge of the licensed administrator on 3/20/2024. 2. There has been a lapse in administrator coverage since 3/20/2024.
Plan of Correction:	The facility shall notify upon discharge of licensed administrator when necessary.
Standard #:	22VAC40-73-520-I
Complaint related:	Yes
Description:	Based on observation, the facility failed to ensure the monthly calendar did not include the type of the activity. Evidence: 1. The monthly activity calendar posted for both the assisted living and memory care unit did not include the type of activity.
Plan of Correction:	The facility shall ensure the Activities Calendar lists types of activities appropriately.