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 and April 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-880 22VAC40-73-1100

Comments:

Type of inspection: Renewal 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 and 04/11/2023 from 8:00 am to 1:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 5 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #1 (admitted 11/29/2023) did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: 1. Resident #3 and Resident #5 did not have a review of appropriateness of each resident?s continued residence in the special care unit in their records.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Description:	Based on observation and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Upon entry into the facility, a broken window was noted. 2. Staff #1 indicated Resident #14 previously occupied the unit and hit the window with an object due to a hallucination Resident #14 experienced. Staff #1 indicated the police were contacted and present following the incident. 3. The incident described by Staff #1 was not reported to the regional licensing office.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-F
Description:	Based on record review, the facility failed to ensure staff?s annual training include at least two hours of training on infection control and prevention. Evidence: 1. Staff #5?s 2023 annual training did not include 2 hours of training on infection control and prevention.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. The facility also failed to ensure each staff person or household member required to be evaluated annually submit the results of a TB risk assessment. Evidence: 1. The first day of work for Staff #2 (hired 1/10/2024) was 2/7/2024; however, the TB risk assessment for Staff #2 was completed on 12/27/2023. 2. Staff #1 was unable to provide a current TB risk assessment for Staff #5 (hired 4/4/22).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. Evidence: 1. Resident #1 (admitted 11/29/2023) have their comprehensive ISP completed; however, there was not a completed fall risk rating in the record of Resident #1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. Evidence: 1. Resident #1 admitted to hospice on 3/7/2024 and fell per nursing notes on 3/21/2024, 3/9/2024, 2/29/2024, 1/29/2024, and 1/13/2024; however, there is not a completed fall risk rating in the record of Resident #1. 2. Resident #2 fell per nursing notes on 2/14/24 and 3/28/24; however, there is no documentation of a fall risk rating being completed after each fall. The last fall risk rating completed for Resident #2 was on 10/4/2023 (at admission). 3. The last fall risk rating for Resident #3 was completed on 10/18/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #1 (admitted 11/29/2023) did not have a completed sex offender screening in their record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete a resident?s UAI at least annually. Evidence: 1. The last UAI for Resident #5 was completed on 7/13/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs. Evidence: 1. Resident #1 has had 5 documented falls from January 2024-March 2024, a change in their diet to pureed as of 4/5/2024, and admitted to hospice as of 3/7/2024; however, the ISP for Resident #1 (dated 11/29/2023) does not reflect their fall risk, special diet, or admission to hospice services. Additionally, Resident #1?s UAI (dated 11/15/2023) indicates the resident is incontinent of bowel and bladder weekly or more; however, this need is not addressed on the resident?s ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-A
Description:	Based on record review, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight. Evidence: 1. The last health care oversight was completed on 3/30/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed ensure the rights and responsibilities of residents in assisted living facilities be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section. Evidence: 1. The following residents did not have current documentation of an annual review of resident rights and responsibilities: Resident #3 and Resident #5.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-620-A
Description:	Based on record review, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist. Evidence: 1. The last dietary oversight completed was completed on 7/23/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: 2 cards of Loperamide 2 mg capsules expired 12/11/2023 and 2/14/2024, PRN Meclizine 12.5 mg tablets expired 1/10/2024, and PRN Acetaminophen 325 mg tablets expired 1/13/2024 for Resident #8, PRN Acetaminophen 325 mg tablets expired 1/13/2024 and PRN Stimulant 8.6-50mg tablets expired on 3/1/2024 for Resident #9, Methylphenidate 5 mg tablets expired 2/28/2024 for Resident #10, and Acetaminophen 325 mg tablets expired 2/22/2024 for Resident #11.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-D
Description:	Based on interview, the facility failed to have readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications. Evidence: 1. Staff #1 and Staff #8 were unable to provide a pharmacy reference book, drug guide or medication handbook.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure the medication cart be locked. Evidence: 1. During a tour of the facility on 04/10/2024, the top drawer of one of the medication carts on the first floor was noted to be unlocked. 2. During a tour of the facility on 04/11/2024, the medication cart on the second floor of the assisted living was observed to be unlocked and unattended. The staff member responsible for medication administration was on the third floor of the facility at the time of observation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-670-3
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. Staff #1 confirmed the facility does not currently employ a qualified individual to supervise medication aides.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-690-B
Description:	Based on record review, the facility failed to ensure for each resident assessed for assisted living care, except for those who self- administer all of their medications, a licensed health care professional, practicing within the scope of his profession, perform a review every six months of all the medications of the resident. Evidence: 1. The last medication review (dated 2/28/2024) provided indicated 4 residents were reviewed. 2. The medication review provided by the facility does not indicate that residents assessed for assisted living care are reviewed every six months as required by the standard.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Resident #1 has a DNR order; however, their ISP (dated 11/29/2023) indicates the resident as a Full Code.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-G
Description:	Based on observation, the facility failed to ensure hot water at taps available to residents be maintained within a range of 105?F to 120?F. Evidence: 1. During a tour of the facility on 4/10/2024, the following hot water taps sampled were not within the required range in the following areas: Unit 1110 (unoccupied) measured 124?F, Resident #4?s bathroom sink measured 125?F, Resident #12?s bathroom sink measured 124?F, Resident #13?s bathroom sink measured 124?F, and Resident #10?s kitchenette sink measured 123?F.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-930-B
Description:	Based on record review, the facility failed to ensure there is a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. On 4/11/2023 around 8:49 am, Resident #15 pressed their call bell. After a few minutes? past, the Licensing Inspector walked to find a staff member with the watch that determines the origin of the signal. The watch did not show the call. Upon testing, it appears the watch does not show calls if it is not in close vicinity of the call.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-970-A
Description:	Based on interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. Staff #1 was unable to provide documentation of fire and emergency evacuation drills conducted in 2023 and 2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-C
Description:	Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. There was no documentation of the monthly checks of the first aid kit from June 2023-November 2023 and January 2024-March 2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. Staff #1 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #6 was hired on 12/29/2023; however, the criminal history record report was obtained on 2/6/2024. 2. Staff #7 was hired on 1/26/2024; however, the facility has not obtained a completed criminal history record report as of 4/10/2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-60-A
Description:	Based on record review, the facility failed to ensure the original report be maintained at the facility where the person is employed. Evidence: 1. Staff #5 was hired on 4/4/2022; however, their staff record did not include their original criminal history record report.
Plan of Correction:	Not available online. Contact Inspector for more information.