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. 9, 2022 and Aug. 10, 2022

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 08/09/2022 from 8:37 am to 1:39 pm and 08/10/2022 from 9:46 am to 2:03 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 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 #:	22VAC40-73-210-B
Description:	Based on record review, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments. Evidence: 1. Staff #3 (hire date 6/18/2018) works as a RMA; however, in 2021, Staff #3 completed 7.5 hours with 1.25 hours in infection control and 2.5 hours in residents? impairments. There is also not evidence to support Staff #3 has received continuing education required by the Virginia Board of Nursing for medication aides. 2. Staff #4 (hire date 7/9/2018) works as a CNA; however, in 2021, Staff #4 completed 7.25 hours with 1 hour in infection control and 3 hours in residents? impairments.
Plan of Correction:	Tidewater Cove staff trainings will be compliant with this regulation. Staff will be tracked by the training manager and staff will be reminded of upcoming trainings due dates. These will be reviewed by the Nursing QA manager monthly for compliance. All outstanding trainings will be complete by September 1, 2022. The annual RMA refresher course will be completed by September 10, 2022 and will be completed annually in September moving forward.
Standard #:	22VAC40-73-250-B
Description:	Based on observation and discussion, the facility failed to ensure all staff records be retained at the facility, treated confidentially, and kept in a locked area. Evidence: 1. During the inspection on 08/09/2022 and 08/10/2022, staff records to include documentation of orientation and initial/annual training, personal and social data, and sworn disclosures and background checks for new hires since last inspection were not available on-site during the time of inspection. Records were sent after the inspection concluded via email on 08/11/2022 and 08/12/2022.
Plan of Correction:	Tidewater Cove will print and retain a hardcopy of required staff and health records.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #1 and Staff #4 work as direct care staff and do not have a current certification in first aid.
Plan of Correction:	Tidewater Cove will ensure staff CPR/First Aid certifications are current. Tidewater Cove staff will have CPR and First Aid training prior to their 60th day of employment. All trainings will be documented and scheduled by the training manager. All employee records will be reviewed every 90 days for compliance by the QA manager.
Standard #:	22VAC40-73-260-C
Description:	Based on observation, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR is be posted in the facility. Evidence: 1. During a tour of the facility on 08/09/2022, a listing of all staff who have certification in first aid or CPR was posted in the multipurpose room and dated 08/27/2021. There were 14 staff members listed with expired CPR/first aid certification per the posting.
Plan of Correction:	Training Manager will update posted CPR/First Aid roster monthly in dining room once employee completes their training. It will also be listed on their individual training record with a certificate placed in file. QA manager will follow up to make sure we are compliant monthly.
Standard #:	22VAC40-73-270-1
Description:	Based on record review, the facility failed to ensure direct care staff be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. Evidence: 1. The facility indicated upon start of inspection there are aggressive residents residing in the facility. There was no evidence that staff have receiving training on methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Plan of Correction:	Training Manager will ensure all staff that is out of compliance is scheduled for crisis management training. Training manager will also monitor staff for annual compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entering the facility on 08/09/2022, the name of the current on-site person in charge was not in a conspicuous place to the public, and staff were unable to initially state who was in charge. Additionally, a whiteboard located in a space non-conspicuous to the public (down one of the resident halls) indicated Staff #6 was in charge from 7a-3p. Staff #6 was not on-site during that time.
Plan of Correction:	Charge person for each shift will be listed in the lobby and updated daily.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to annually complete a risk assessment for tuberculosis on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The last risk assessment for TB completed for Resident #1 is 07/02/2021.
Plan of Correction:	Annual risk assessment will be completed by the Nursing Supervisor on every resident. Nursing administrator will review to ensure compliance with the VDH forms, printed and placed in charts.
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 #5 admitted into the facility on 06/24/2022; however, the sex offender screening was completed on 08/09/2022.
Plan of Correction:	Virginia State Police Sex Offender report will be completed on the day that the new resident is accepted for admission and placed in the chart. The date this search is completed will be printed on the results page.
Standard #:	22VAC40-73-440-F
Description:	Based on record review, the facility failed to ensure the UAI be completed within 90 days prior to admission to the assisted living facility, except that if there has been a change in the resident's condition since the completion of the UAI that would affect the admission, a new UAI shall be completed. Evidence: 1. Resident #4 admitted to the facility on 10/06/2021; however, their admitting UAI was completed 06/16/2021.
Plan of Correction:	We will ensure that a new UAI for all new residents is completed within 30 days of admission and updated as needed.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. Resident #4 admitted to the facility on 10/06/2021; however, there was not an ISP in their resident record.
Plan of Correction:	We will ensure all ISPs? are printed and in the chart going forward. QA manager will print care plans on the day of completion.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to complete individualized service plans at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Three of the seven resident records reviewed did not have an updated ISP: Resident #1?s last ISP completed 07/13/2021, Resident #3?s last ISP completed on 06/29/2021, and Resident #6?s last ISP completed 06/02/2021.
Plan of Correction:	All ISP?s will be printed immediately and entered into client records the day they are completed. QA manager will print care plans on the day of completion.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person. Evidence: 1. The records of Staff #1and Staff #4 do not include written acknowledgement of having been so informed of the review of the rights and responsibilities of residents. 2. The review of resident rights and responsibilities for Staff #1, Staff #2, Staff #3, and Staff #4 were not available during the time of the inspection.
Plan of Correction:	Onboarding manager will review resident rights with staff annually during the month of August and get them signed. It will be documented on their training record and the signed copy put in their employee record.
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 on 08/09/2022 and 08/10/2022, the meal menus posted in the multipurpose room indicated ?Week 1;? however, it did not indicate the month or days date.
Plan of Correction:	ALF administrator will ensure monthly menu is posted with the current month, year, and days of the month.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. There is no sworn disclosure in Staff #4?s record. 2. The sworn disclosure completed by Staff #9 and Staff #10 were not dated. 3. The sworn disclosure completed by Staff #11 is not properly completed. Staff #11 checked both yes and no for pending charges. 4. The sworn disclosure completed by Staff #12 and Staff #13 is incomplete as there is no indication of yes or no to the questions asked on the form. 5. There is no Sworn Statement or Affirmation for Adult Facility Employees completed for Staff #14 and Staff #15. The sworn disclosure completed by Staff #14 and Staff #15 are for Exempt Child Day Centers.
Plan of Correction:	DSS sworn disclosure will be reviewed by the training manager and QA manager for proper completion when received from HR on each new employee.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, 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 #16 was hired on 12/31/21; however, the completed criminal history record report through the Virginia State Police was not received by the facility until 2/15/22.
Plan of Correction:	Moving forward all criminal background checks will be place in staff records within 30 days of hire.