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. 15, 2023

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: 08/15/2023. 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: 68 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 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, and the staff schedule. Water temperature was measured, and the call bell system was monitored. 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 #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #2 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	Effective immediately, the Auditing Nurse will audit at least 2 resident charts per week to ensure that the form indicating whether placement in a SCU is appropriate for a resident with a serious cognitive impairment; per standards, is in place. This information will be provided upon entry into the facility and/or immediately following a resident/client change of condition where a SCU is identified as appropriate.
Standard #:	22VAC40-73-1140-B
Description:	Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section. Evidence: 1. Staff #2 (hired 11/28/2022) and Staff #3 (hired 6/27/2022) work in the safe, secure environment; however, there was not documentation that Staff #2 and Staff #3 have completed at least 10 hours of training in cognitive impairment within four months of their hire date.
Plan of Correction:	Effective immediately, the Onboarding Navigator shall ensure that all new hires (direct care staff) receive the required hours of training in cognitive impairment that meets the DSS standards. Evidence of the required training shall be maintained according to standards and readily available for review upon request. The ALF Administrator may randomly audit the employee charts to ensure compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard. Evidence: 1. The physical examination for Resident #4 did not include a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H. 2. Resident #6 admitted to the facility on 08/03/2023; however, the physical examination for Resident #6 was completed on 06/12/2023.
Plan of Correction:	Effective immediately the Referral Navigator will review all new admission paperwork to include the pre-admission physical examination form is completed within the required timeframe ? per regulations. The Auditing Nurse will review all new admission charts (at least 3 per week) to ensure continued compliance. This audit shall include ensuring that the physical examination form includes a statement that the individual does not have any condition or care needs prohibited by DSS regulations.
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 #3 (admitted 04/20/2023) did not have a completed sex offender screening in their record.
Plan of Correction:	Effective immediately, the Referral Navigator will conduct the registered sex offender check at the time the referral is received; prior to admission. The Auditing Nurse will ensure the results are located in the resident/client medical chart no later than the date of admission. The ALF Administrator will review at least one chart per month to ensure consistent compliance with DSS regulations.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure the UAI for residents be completed whenever there is a significant change in the resident's condition. Evidence: 1. Resident #2 was admitted to hospice services on 5/9/2023; however, an UAI was not completed for this significant change. The last UAI for Resident #2 was completed on 12/30/2022.
Plan of Correction:	Effective immediately, the Nurse Manager and/or Nurse Supervisor notifies the residents? care manager is informed of any change of condition which requires an updated UAI. The case manager shall ensure the UAI is updated immediately following a change of condition.
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 their health, safety, and welfare. Evidence: 1. Resident #4 admitted to the facility on 05/16/2023; however, there was no preliminary plan of care on or within seven days prior to the day of admission in Resident #4?s record.
Plan of Correction:	Effective immediately, the Nurse Manager, or Nurse Supervisor, will ensure that a comprehensive ISP is developed no later than the date of admission into the facility, based on the needs of the resident, protecting his/her health, safety and welfare. The Nurse Auditor shall randomly audit the new admission charts no later than 72 hours after admission to ensure the ISP is in place.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan be completed within 30 days after admission. Evidence: 1. Resident #4 admitted to the facility on 05/16/2023; however, there was not a comprehensive individualized service plan within Resident #4?s record.
Plan of Correction:	Effective immediately, if the facility completes a preliminary ISP, we will ensure that a comprehensive ISP is completed within 30 days after admission.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #2 obtained a DNR and was admitted to hospice services on 5/9/2023; however, the resident?s ISP was not reviewed or updated for this significant change. Resident #2?s ISP (dated 02/28/2023) indicates the resident as a full code and does not reflect or address the resident?s admission to hospice.
Plan of Correction:	Effective immediately, within 72 hours after a significant change of a resident?s condition, the ISP shall be updated to reflect the change and care as a result of the change. The Auditing Nurse and ALF Administrator shall audit the chart to ensure DSS regulation compliance; at least 1x monthly.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. Resident #6?s record did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents.
Plan of Correction:	Effective immediately, the Activities Coordinator shall review the resident rights and responsibilities every January with each client/resident and/or his/her legal representative, or responsible party as stipulated in the DSS regulations.
Standard #:	22VAC40-73-690-F
Description:	Based on interview and record review, the facility failed to ensure the medication review be provided to the administrator within 10 days of the completion of the review and maintained in the facility files for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident's record. Evidence: 1. During the onsite inspection, Staff #1 indicated the last medication review was completed in March 2023; however, during the time of the inspection, the report was not maintained at the facility and unavailable for review. Additionally, the resident records reviewed did not indicate a review occurred or any recommendations if specified.
Plan of Correction:	Effective immediately, the facility will no longer accept the emailed version of the pharmacy review. The facility will require the pharmacy to provide their review on a separate document (not written on each individual POS); in summary form. This summary shall be maintained on the computer with readily available access when requested or in a binder, located in the Administrators office for review; as requested. The review shall include any specific recommendations as required by DSS. The Nursing Supervisor shall ensure the receipt and proper filing of the report and maintain its availability is readily available, upon request.
Standard #:	22VAC40-73-940-A
Description:	Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 06/09/2022.
Plan of Correction:	Effective immediately, the building supervisor shall ensure that the annual inspection is completed per DSS regulations. If there is a staffing shortage at the city level, the building supervisor will notify the ALF Administrator who will notify DSS immediately upon being notified of the delay in inspection.
Standard #:	22VAC40-73-950-F
Description:	Based on interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Evidence: 1. Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.
Plan of Correction:	Effective immediately and at least twice annually, the ALF Administrator will review the emergency preparedness plan. The review will be signed and dated to reflect the review and revisions; if any.
Standard #:	22VAC40-73-970-E
Description:	Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills include the items identified in the standard. Evidence: 1. The record of the required fire and emergency evacuation drills did not include the following: the number of residents participating, any special conditions simulated, weather conditions, and problems encountered, if any.
Plan of Correction:	Effective September 1, 2023, the facility shall utilize the DSS approved form to document a record of fire and emergency evacuation drill to include the items identified in the standard. The Building Supervisor will ensure that these records are maintained in a binder and ready for review as requested.
Standard #:	22VAC40-73-980-C
Description:	Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. The first aid kit was last checked on 03/29/2023.
Plan of Correction:	Effective immediately and monthly thereafter, the Nurse Manager shall ensure the first aid kits are checked per DSS standard. The Building Supervisor and Activities Coordinator shall also ensure the first aid kits located in any facility vehicles are maintained per the DSS standard. A record of the checklist audit shall be maintained in each kit, if applicable and/or in a binder for review as requested. The Auditing Nurse and/or designee shall be responsible for ensuring compliance.
Standard #:	22VAC40-73-990-C
Description:	Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. The facility could not provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of Correction:	Effective immediately, the Building Supervisor will ensure that any and all participation in practice exercises or actual events of resident emergences are documented according to DSS standards. This record shall be maintained by the Building Supervisor and audited, randomly, by the ALF Administrator.
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. The sworn disclosure completed by Staff #5 and Staff #6 were not dated.
Plan of Correction:	Effective immediately, the organizations? Human Resources Department shall ensure that the sworn statement or affirmation is completed prior to employment of any new applicants. This form will be readily available by the ALF Administrator and ready for review as/when requested.
Standard #:	22VAC40-90-50-A
Description:	Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency contain information listed in the standard. Evidence: 1. The record of Staff #4 indicates their background check is not completed by the Virginia State Police.
Plan of Correction:	Effective immediately, the ALF Administrator shall ensure that any temporary agency being utilized by the facility will run a background check (by the VSP). In the event that the temporary agency does not utilize this agency (VSP) for background checks, the facility shall require the temporary agency workers to report to the Human Resources Office to have the required checks conducted. In the interim, the facility will ensure that any temporary workers having direct care responsibilities, be accompanied by a facility employee, for the shift and until background results have been returned and approved.