VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tidewater Cove, Operated by Western Tidewater CSB
2536 East Washington Street
Suffolk, VA 23434
(757) 935-1415

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Aug. 19, 2019 , Aug. 20, 2019 and Aug. 21, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Criminal History Record Report

Technical Assistance:

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Comments:

An unannounced renewal inspection was conducted by two Licensing Inspectors from the Eastern Regional Office. The inspection was conducted on August 19, 2019 from 8:00 AM until 3:30 PM, on August 20, 2019 from 9:00 AM until 1:19 PM, and August 21, 2019 from 11:04 AM until 1:04 PM. There were 63 residents in care. During the inspection a tour of the building and grounds was conducted, a meal was observed as posted on the menu. A medication pass observation was conducted as well a review of the medication cart. Resident records and staff records were reviewed to include criminal background checks for new staff hired since the previous inspection. Resident interviews were also conducted. Construction in the back hallway is currently taking place due to water damage. Safety precautions are in place. Discussed the updated Disclosure form for all current and new residents. Remember to review admission forms, ISPs and public pay UAI?s for accuracy and completeness, to include description of allergies and possible reactions on ISP, if known. Discussed categories and times on the activities calendar. The facility received violations in the areas of Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds, Emergency Preparedness. Please complete the `Plan of Correction? and `date to be corrected by? for each violation cited on the violation notice and return within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the noncompliance with the standards. 2. Measures to prevent re-occurrence and 3. Person(s) responsible for implementing each step and/or monitoring any preventative action. If you have any questions please contact your licensing inspector at 757-353-0430.

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview, the facility failed to ensure the fall risk rating was reviewed and updated after each fall. Evidence: During review of resident #5's record, the resident was assessed at assisted living level of care per the uniform assessment instrument (UAI) dated 06-13-19. The initial fall risk rating upon resident's admission was dated 06-14-19, and was updated on 08-12-19. However, according to staff nursing notes, the resident had a fall on the following dates: 06-15-19, 06-20-19, 06-26-19, 08-06-19, and 08-17-19. Review of the resident's record revealed the fall risk rating was not updated after each of the aforementioned falls. 2. During interview, staff #1 acknowledged the fall risk rating was not updated after each of the falls mentioned.
Plan of Correction:	All nursing staff has been retrained regarding the regulation for fall risk assessments. They have been instructed it must be completed even if the resident gets onto the floor without a witness as we cannot be sure this was intentional, or if it was a fall because a fall is defined as a change in elevation. Administrator will be checking all documentation and will compare incident reports to fall risk assessments. The monthly nurses meeting will be devoted this month to the inspection results. Retraining and review of State Regulations will be included. The charge nurse will review all incident reports before turning into administrator daily. Administrator must approve all documentation in EMR. Administrator will make sure there is a fall risk assessment for every recorded fall.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure the discharge statement include the date of the actual discharge from the facility. Evidence: During review of resident #9's discharge statement, the date of the resident's discharge was not documented on the discharge statement. During interview, staff #1 indicated the resident was discharged on 07-02-19 and acknowledged the missing date on the form.
Plan of Correction:	Correct date was added to this discharge notification during the inspection while inspectors were onsite. Completed Discharge Notifications will be review by another staff members for holes prior to filing. Administrator will complete Discharge Notification, give to another staff member familiar with this form for review. It will then be filed in closed files.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) include a description of the resident's identified need based upon the Uniform Assessment Instrument (UAI). Evidence: 1. During review of resident records, resident #12's ISP dated 09-25-2018 did not include the resident's short-term memory loss as indicated on the Uniform Assessment Instrument (UAI) dated 11-09-2018. 2. Staff #1 acknowledge the missing information on resident #12's ISP.
Plan of Correction:	All ISP's will be monitored for all current needs documented on the UAI to include Mental Capacity and deficiencies. When comprehensive ISP is completed by administrator, it will be reviewed by another administrative person to insure all areas were addressed. Administrator and CSB employees will regularly audit ISP's. This will be completed with initial and also spot checks done monthly.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure physician or other prescriber orders,for administration of all prescription and over-the-counter medications and dietary supplements identify the diagnosis for each drug. Evidence: 1. During the medication observation on 08-19-19, staff #2 administered Sodium Bicarbonate 650mg to resident #12 and Hydroxizine 50mg to resident #6. 2. During a review of resident records: a. Resident #12's physician's order dated 08-09-19 did not include the diagnosis for Sodium Bicarbonate 650mg, and; b. Resident #6' physician's order dated 08-02-19 did not include the diagnosis for Hydroxyzine 50mg 3. Staff #1 acknowledged the missing diagnosis for the aforementioned medications.
Plan of Correction:	All MAR's and Physician Orders were checked during the reconciliation process for the September documents. Missing diagnosis were put onto MAR while inspectors were onsite. Charge Nurse will audit all orders monthly during reconciliation for completed diagnosis for all medications. RMA's will also monitor for diagnosis with each new order and during the first week of each month for existing orders. Ongoing monitoring will be done by staff nurses, charge nurse and administrator will do checks when new orders are received and frequently during the month.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and interview, the first aid kit in the facility was not complete to include hand sanitizer and scissors. Evidence: During review of car #3's first aid kit on 08-19-19 with staff #1, the hand sanitizer and the scissors were missing from the first aid kit. Staff #1 acknowledged the missing items.
Plan of Correction:	Scissors and hand sanitizer were placed in this first aid box during inspection while inspectors were onsite. Monthly first aid kit inspections will be done by RMA's and Staff Nurse's. Charge nurse will make checks randomly to check for compliance on all first aid kits monthly. All nursing staff to include charge nurse will monitor all first aid kits frequently. Administrator will also monitor sporadically for compliance.