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. 16, 2021

Complaint Related: No

Areas Reviewed:

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:

Posting the name of the current on-site person in charge.

Comments:

A renewal inspection was initiated on 08-16-2021 and concluded on 12-02-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 62. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. Two inspectors conducted the on-site portion of the inspection on 11-18-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on observation and documentation, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. On 11-18-2021, prior to entering the facility, a window was observed boarded closed. During a tour of the facility, Staff #5 indicated that Resident #5 physically went through the closed window at approximately 2:00 a.m. a few weeks ago. 2. A review of the requested incident report states staff were alarmed by another resident that ?someone was trying to come through? their window on 10-23-2021. Staff then observed Resident?s 5 window was broken out and the resident standing outside the facility. Resident #5 went to the ER with an abrasion to their hand. 3. Staff #5 acknowledged the incident was not sent to the regional licensing office.
Plan of Correction:	Effective 11/18/21 all incidents will be reported to DSS inspector within 24 hours and incident report filed.
Standard #:	22VAC40-73-210-F
Description:	Based on documentation review, the facility failed to ensure at least two of the required hours of annual training for direct care staff focus on infection control and prevention and at least four on topics related to residents' mental impairments. Evidence: 1. Staff #2 (hired on 05-22-2018) from 5/22/20-5/22/2021 participated in .5 hours in infection control and 0 in topics related to mental impairments. Additionally, Staff #3 (hired on 03-26-2018) from 3/26/20-3/26/21 participated in 1 hour of training related to residents? mental impairments. 2. Staff #5 submitted all the training records for Staff #2 and Staff #3 which did not include the required hours aforementioned.
Plan of Correction:	Effective 12/22/21 the required hours of training will be implemented once again.
Standard #:	22VAC40-73-250-D
Description:	Based on documentation review and discussion, 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. Evidence: 1. Staff #1 was hired 04-26-2021 with a tuberculosis risk assessment completed on 04-29-2021.
Plan of Correction:	No one has ever had patient contact without a negative PPD when hired. Their hire date will always be different as they receive their PPD the day that they onboard in the HR office. Until the PPD is read 48 hours later they are doing trainings in a secure area without patient contact. During this time their initial ALF training is also completed.
Standard #:	22VAC40-73-260-A
Description:	Based on documentation review, the facility failed to ensure each direct care staff member maintain a current certification in first aid. Evidence: 1. Staff #1 (hired on 04-26-2021 as a CNA), Staff #2 (hired on 05-22-2018 as an RMA), and Staff #3 (hired on 03-26-2018 as an RMA) did not have a current certification in first aid. 2. Staff #5 acknowledged there is not documentation of a current certification in first aid for Staff #1, Staff #2, and Staff #3.
Plan of Correction:	Effective 12/22/2021 all staff will be scheduled to receive certification in CPR and First Aid if the current one on file is expired. All staff will be certified by 2/1/2022.
Standard #:	22VAC40-73-440-L
Description:	Based on documentation review and discussion, the facility failed to maintain the completed UAI in the resident?s record. Evidence: 1. Resident #2?s UAI dated 09-19-2020 does not address whether the resident requires assistance with bowel or bladder continence. 2. Staff #5 acknowledged the missing information in the UAI for Resident #2.
Plan of Correction:	Going forward UAI?s will be double checked for accuracy and completion by the licensed administrator. An updated UAI was completed on 9/14/21 which included bowel and bladder.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #1?s UAI dated 06-24-2021 documented the need of mechanical assistance with toileting; however, the resident?s ISP dated 06-29-2021 states did not include documentation of the need. 2. Neither the current UAI dated 02-08-2021 or ISP dated 02-24-2021 for Resident #4 list the resident?s allergy to codeine. Resident #4?s allergy is noted on their admitting physical examination dated 02-09-2021 and under allergies in the Physician?s Orders Sheet signed 11-08-2021. 3. Staff #5 acknowledged Resident #4?s allergy was not captured and identified on their ISP.
Plan of Correction:	Client #1 from the day of admission was ambulatory with no need for assistance with toileting. Upon nursing and administrator assessments on admission, it was determined that this client was totally independent with toileting. Allergies will be included on all ISP?s to include name of allergy and side effects experienced
Standard #:	22VAC40-73-520-I
Description:	Based on observation and documentation, the facility failed to ensure the current month activity schedule be posted in a conspicuous location in the facility or otherwise be made available to residents and their families. Evidence: 1. During a tour of the facility with Staff #6, the schedule of activities for week of 10/11/2021-10/17/2021 were posted in the multipurpose room. 2. Staff #6 acknowledged the current month activity schedule was not posted.
Plan of Correction:	Monthly activity schedules are posted both on the bulletin board in the multipurpose room and in each client?s room on the last day of each month. We will continue to post as the regulations read.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and documentation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During the tour of the facility with Staff #6, the meal menus dated 11/08/2021-11/14/2021 and 11/222021-11/28/2021 were posted in the multipurpose room. The current meal menu for 11/15/2021-11/21/2021 was not posted. 2. Staff #6 acknowledged the meals for the current week were not posted.
Plan of Correction:	Current week?s menu had been removed to make a change for the following day. We will continue to be compliant with state regulations.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to the interior and exterior of all buildings are maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility with Staff #6, exposed plumbing and missing dry wall around the tub in the women?s shower room was observed. Trash throughout the courtyard to include cups, cans, and cigarette boxes was also present. Also, exposed wood and wires were noted in a designated construction area within the building that was accessible to residents. 2. Staff #6 acknowledged the current condition of the bathroom and the repairs needed on the tub. Staff #6 was unable to state how long it has been out of repair and when it will be completed. Staff #5 and Staff #6 also acknowledged the waste noted throughout the courtyard. Additionally, Staff #5 and Staff #6 acknowledged there were not any barriers or signs to limit the accessibility to the designated construction area of residents.
Plan of Correction:	Dry wall around tub in ladies shower room was repaired on December 3, 2021. The grounds are now being monitored three times daily for rubbish and any trash that is placed on the ground by our residents. Effective 1/1/22, a sign off sheet will be put into place to be signed by maintenance or housekeeping, walk through of all areas will be done in the morning, noon and the evening Doors were installed to prevent patient access to the construction area. Building rounds will be added 3 times a day to ensure posting are still posted while construction is still in process or any other future projects.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #5 provided a list of newly hired staff and dates of hire; to include Staff #7 (date of hire on 07-16-2021). 2. Staff #5 acknowledged Staff #7?s criminal history record report was dated 06-17-2021; however, it was not documented as received by the facility until 12-01-2021.
Plan of Correction:	Effective 12/22/21 no employee will be permitted to continue to have patient contact after 30 days without a criminal history background check available on file with HR and the facility.