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 13, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/13/2024 from 9:20 am to 10:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/15/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 #:	22VAC40-73-120-A
Description:	Based on record review, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment. Evidence: 1. The record of Staff #2 (hired 04/30/2024) did not complete their staff orientation and initial training within the first seven working days of employment.
Plan of Correction:	Effective immediately all WTCSB staff and/or outside staffing agency people will receiving a complete orientation as outlined in the DSS regulations, on the first day he/she enters the facility but no later than the first seven working days of employment. The departmental manager and or Administrator designee shall ensure required orientation and training checklist shall be completed and maintained.
Standard #:	22VAC40-73-280-E
Description:	Based on interview, the facility failed to ensure no employee be permitted to work in a position that involves direct contact with a resident until a background check has been received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such person works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90). Evidence: 1. Staff #2 worked as direct care staff and did not have a completed background check until 06/13/2024. Staff #1 was not under the direct supervision of another employee at the time an alleged incident on 05/13/2024.
Plan of Correction:	Effective immediately all staff and/or agency workers shall work alongside a TWC staff persons until his/her background check has been received as required by the DSS regulations. The facility Scheduled shall ensure compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. On 05/13/2024, Staff #2 administered Resident #1 the evening medications (total of 7) for Resident #2.
Plan of Correction:	Effective immediately, all new staff and/or agency personnel shall review the facility's Medication Management policy and procedures to ensure medication are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice. The Nurse Managers or their designee shall ensure the Medication Management policy is reviewed by the staff and agency personnel.
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. The criminal history record report for Staff #2 (hired 04/30/2024) was completed on 06/13/2024.
Plan of Correction:	Effective immediately, all criminal background checks will continue to be submitted to the home office for processing. These background checks shall be processed immediately upon receipt by the home office. The facility's home office human resources shall ensure timely processing of all submitted background check requests. The facility shall receive notification of the completion and results - prior to the 30th day of employment. The Administrator shall ensure continued compliance per DSS regulations.