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 30, 2023

Complaint Related: Yes

Areas Reviewed:

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

Technical Assistance:

22VAC40-73-870

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: 06/30/2023 from 09:05 am to 11:20 am. Eight complaints were received by VDSS Division of Licensing on 6/16/2023 (2), 6/19/2023 (2), 6/20/2023, 6/21/2023, and 6/23/2023 (2) regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Provisions, and Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of interviews conducted with residents: 7 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: Resident Care and Related Services. 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 #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: 1. The following are the documented completion or attempts of bathing on the records reviewed: Resident #1 ? 6/7/23, 6/11/23, 6/14/23, 6/21/23, and 6/28/23 and Resident #2 ? 6/2/23, 6/7/23, 6/14/23, 6/21/23, and 6/28/23. The documentation for Resident #1 and Resident #2 does not indicate the residents are receiving bathing at least twice a week.
Plan of Correction:	Effective immediately, at least 1x per week, nursing manager shall review the daily shower sheets to ensure all residents are receiving showers per his/her care plan/at least 2x weekly. In the event that a resident refuses, two additional attempts shall be made on the same day to offer a shower. If the resident continues to refuse, it will be documented on the shower sheet and another attempt will be made on the following day. Any alteration of the amount of weekly showers are requested by the resident or his/her legal guardian, such request shall be indicated on the resident?s ISP/Care Plan.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The May 2023 and June 2023 MAR for Resident #4 indicates the following medications were not available for administration on the following days: Clozapine 100mg tablet on 5/1/23-5/2/23, 5/31/23, 6/5/23-6/9/23, and 6/11/23-6/14/23 and Diclofenac Sodium 1% gel from 5/3/23-5/12/23, 5/26/23-5/28/23, and 6/18/23-6/19/23.
Plan of Correction:	Effective immediately a system will be put in place; with a color coded manilla folder distinction, to ensure that all orders are faxed to the pharmacy and received in an appropriate time. If the regular pharmacy is unable to deliver ordered medications, the facility back-up pharmacy will be utilized. This will ensure all medications ordered are filled and delivered in a timely manner. The Nursing Supervisor will review all medication count audits to ensure the nursing managers are re-ordering medications at least 5 days in advance to avoid running out.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the MAR include the identified items in the standard. Evidence: 1. The following medications on Resident #4?s June 2023 MAR did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Aspirin 81 mg tablet, Diclofenac Sodium 1% gel, Latanoprost 0.005% eye drops, and Meloxicam 7.5mg tablet.
Plan of Correction:	Effective immediately, the Nursing Managers and Supervisor will review all orders for all residents to ensure the diagnosis is indicated on each medication order. The Nursing Managers will conduct an audit of all orders to ensure all required information is indicated; on a monthly basis.