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: June 15, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

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: 6/15/2022 from 10:13 am to 1:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 04/25/2022 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, and Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 14 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The licenses/certifications of staff administering medications as well as the staff schedule was reviewed. 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: Staffing and Supervision. 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 #:	22VAC40-73-290-A
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Any absences, substitutions, or other changes shall be noted on the schedule. Evidence: 1. Staff #1 and Staff #2 provide the staff schedule from 05/16/2022-06/19/2022; however, it did not indicate all absences, substitutions, or other changes on the schedule. For example, on resident?s MAR, Staff #3, Staff #4, Staff #5, and Staff #6 are notated as administering medications; however, these individuals are not on the schedule as working on the days they are documented as administering medications to residents. 2. Staff #1 and Staff #2 acknowledged the schedule does not reflect all absences, substitutions, or other changes.
Plan of Correction:	PRN staff in question was added to call center, for timekeeping purposes. All PRN staff were checked and added to call center, for timekeeping purposes. All new hires will be added to proper facilities. Tidewater Cove Administrator and/or designee will audit employee files quarterly for accuracy for scheduling and timekeeping.
Standard #:	22VAC40-73-880-A
Complaint related:	No
Description:	Based on discussion, the facility failed to have at least one movable thermometer available in each building for measuring temperatures in individual rooms that do not have a fixed thermostat that shows the temperature in the room. Evidence: 1. During a tour of the facility on 06/15/2022, one hall was noted with 3 large fans in the hallway. There was a thermostat noted in the hallway that was noted to be at 78 degrees. 2. Staff #1 acknowledged the individual resident rooms do not contain a thermostat and the facility did not have a movable thermometer available to show or determine the room temperature of resident rooms.
Plan of Correction:	HVAC service was called to assist and resolve matter and an estimate to fix the issue(s) was produced. Air temperature thermometers were purchased. Maintenance personnel or designee will check resident room temperatures, at random. Maintenance personnel will report any room temperatures above 78 degrees to Administrator and Director for further follow up with the HVAC company as needed.
Standard #:	22VAC40-73-880-D
Complaint related:	No
Description:	Based on discussion, the facility failed to develop and implement a plan to protect residents from heat-related and cold-related illnesses in the event of loss of air-conditioning or heat due to emergency situations or malfunctioning or broken equipment. Evidence: 1. During a tour of the facility on 06/15/2022, one hall was noted with 3 large fans in the hallway. Staff #1 and Staff #2 stated the facility is working through an issue with air-conditioning on the unit. 2. Staff #1 and Staff #2 were not able to provide a documented plan to protect residents from heat-related illnesses in the event of loss of air-conditioning due to malfunctioning or broken equipment.
Plan of Correction:	Not available online. Contact Inspector for more information.