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: Sept. 23, 2020 , Sept. 24, 2020 , Sept. 25, 2020 and Sept. 28, 2020

Complaint Related: No

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on September 23, 2020 and concluded on September 28, 2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 60. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 4 staff records, staff schedules, criminal record checks and sworn disclosure statements of new staff, fire and emergency drills, health and fire inspection reports, and dietary and healthcare oversights submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The following topics were discussed during the inspection: First Aid/CPR certification, resident agreements, training hours, and individualized service plans (ISPs).

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and discussion, the facility failed to ensure the assisted living facility provided a statement to the prospective resident and his legal representative, if any, that discloses information about the facility, including fees charged for accommodations, services, and care, including clear information about what is included in the base fee and all fees for additional accommodations, services, and care. Evidence: 1. Resident #4 admitted 07-28-20, and resident #5 admitted 01-02-20. Neither residents? disclosure statements documented the specific cost of admission, including the cost of the Auxiliary Grant rate or private pay rate. 2. Staff #2 confirmed that the Disclosure statements provided to resident #4 and resident #5 did not disclosure the specific rate for the Auxiliary Grant Rate or private pay rate.
Plan of Correction:	Going forward from today all new admissions will have the dollar value listed on page 1 of their disclosure statement. In the past we have listed AG rate in the area which is in violation of this regulation. All current disclosure statements that are incorrect will be corrected in the next 30 days.
Standard #:	22VAC40-73-70-A
Description:	Based on record review and discussion, 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. Resident #1 was discharged on 09-06-2020. The ?Discharge Notification and Statement? documented, ?Reason(s) for discharge: Assaulted another resident. Removed by SPD [Suffolk Police Department]?? 2. An internal facility incident report was reviewed during inspection on 09-28-20 that documented, ?[Resident #1] stabbed [resident #2] with a pen in her left shoulder area?? 3. Staff #2 confirmed the regional licensing office did not receive notification of the incident within 24 hours.
Plan of Correction:	All future occurrences will be reported to licensing within 24 hours. The incident occurred on a holiday weekend and was simply overlooked.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and discussion, the facility failed to ensure an original criminal record report was included in the staff record. Observation: 1. Staff #1?s date of hire was 02-26-2020. There was no documentation of a criminal record report in the staff?s record. 2. Staff #2 confirmed that there were no criminal record reports in staff #1?s record.
Plan of Correction:	Going forward from today, criminal background checks will be forwarded to the administrator the day they arrive to the corporate office. A binder will be kept under double lock and key in the administrator's office. New employees will not be able to have patient contact until it is received by the administrator.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and discussion, the facility failed to ensure the medication management plan was followed to include methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident #3?s August Medication Administration Record (MAR) documented on 08-03-2020 and 08-04-2020, ?Some 9 PM meds? as medication/dosage and results/response documented ?Some not available?. 2. The August MAR documented Carbamazepine 40 mg and Carvedilol 6.25 mg were not administered on the evening of 08-03-2020, but it was not clear which medications were not administered on 08-04-2020. 3. Staff #2 confirmed medications were not administered as they were not refilled in a timely manner to avoid missed dosages.
Plan of Correction:	The resident was readmitted to the facility on 8/2/20 from an extended hospital stay. I have spoken to the staff member that administered meds on 8/4/20 and educated her on the proper procedure for documenting meds and that there should be a nurses note regarding reason for not administering med. These two medications had to be ordered by the pharmacy which caused us to receive them on 8/5/20 from the pharmacy. Doctor was notified. Pharmacy notified today that when a weekend admission comes in they will have to provide medications that day from another pharmacy if necessary. This was not a refill situation.