VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hilton Plaza, Inc.
311 Main Street
Newport news, VA 23601
(757) 596-6010

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: June 12, 2024

Complaint Related: No

Areas Reviewed:

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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal An unannounced renewal inspection was conducted on 6-12-24 with two licensing inspectors from the Peninsula Licensing Office. Ar 07:45 a.m./Dep 13:15 p.m.) The facility census was 54. 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication pass/ breakfast meal Additional Comments/Discussion: psychotropic medication/ infection control policy 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observation and staff interviewed, the facility failed to ensure that staff followed the facility?s policies and procedures for hand hygiene. Evidence: 1. On 6-12-24 during the medication pass observation with staff #2, staff was observed using the facility?s hand sanitizer. The hand sanitizer was dated 6-2023. Staff #2 stated not knowing that hand sanitizers had an expiration date. 2. Staff #1 was informed of the expiration date on the bottle of the hand sanitizer used by staff #1 during the medication pass. Staff #1 stated the staff should be washing hands between medication pass in accordance with the facility?s policies and procedures. 3. The facility policies and procedures documented handwashing and the use of hand sanitizer. 4. The hand sanitizer used by the facility during the medication pass noted an expiration date of 6-2023. 5. Staff #1 and #2 acknowledged the hand sanitizer was expired.
Plan of Correction:	Administrator will ensure that hand sanitizer is available at all times and will ensure that the expiration date is current. Correction Date: 6/12/2024
Standard #:	22VAC40-73-240-D
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure subsequent tuberculosis (TB) evaluation and reports were completed for one of three staff records reviewed. Evidence: 1. On 6-12-24, staff #1?s tuberculosis assessment was dated 5-4-23. The staff?s date of hire noted as 8-25-20. 2. Staff #1 acknowledged the tuberculosis assessment was not current.
Plan of Correction:	Administrator will ensure that current risk assessments are completed annually by using the date of hire as a guideline by staff, who will monitor and report this information to the Administrator. Administrator will monitor assessments to ensure that the assessor uses the correct date on the form. Correction Date: 6/17/2024
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that it had a physical examination for a resident within 30 days preceding the resident?s admission. Evidence: 1. On 6-12-24, resident #5?s record noted the resident?s physical examination was dated 12-4-23. The resident?s date of admission to the facility was noted as 9-14-23. 2. Staff #1 acknowledged the resident physical was completed 12-4-23, after the resident?s admission date.
Plan of Correction:	Staff will ensure that no resident is admitted without proper documentation of a physical exam prior to admission ? dated within 30 days. Correction Date: 6/12/2024
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan (ISP) included all assessed needs for a resident. Evidence: 1. On 6-12-24 resident #5?s uniformed assessment instrument (UAI) dated 7-8-23 documented resident was disoriented some spheres sometime and assessed as having aggressive/abusive behaviors. These assessed needs were not documented on the resident?s ISP dated 10-13-23. The resident?s mental health progress notes documented the resident receiving services from a community service provider. This need was not documented on the resident's ISP. 2. Staff #1 acknowledged the aforementioned resident?s ISP did not include all assessed needs.
Plan of Correction:	Administrative staff will ensure that the ISP includes all assessed needs for client and Administrator will double check each ISP as they are completed. Correction Date: 7/12/2024
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s annual/reassessed individualized service plan (ISP) included all assessed needs. Evidence: 1. On 6-12-24, resident #2?s uniformed assessment instrument (UAI) dated 2-7-24 noted the resident receive mental health services from a community services board. The resident record included mental health progress reports from a community service board. The resident?s psychotropic treatment plan noted the resident is administered Risperdal Consta intramuscularly every 14 days and Uzedy ER injection under the skin once a month by the community service board. These services were not on the resident?s ISP dated 2-8-24. 2. Resident #3?s UAI dated 8-16-23 noted resident incontinent of bladder and psychosocial assessed as having judgement problems. The ISP dated 8-17-23 did not include these assessed needs. 3. Staff #1 acknowledged the aforementioned residents? ISP did not include all assessed needs.
Plan of Correction:	Administrative staff will ensure that the ISP includes all assessed needs for client and Administrator will double check each ISP as they are completed. Correction Date: 7/12/2024
Standard #:	22VAC40-73-650-B
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure all physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include, the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. On 6-12-24, resident # 1?s physician?s orders sheet (POS) dated 4-11-24 did not include a diagnosis for Ibuprofen. 2. Resident #3?s physician?s telephone order signed and dated 4-26-24 did not include a diagnosis for Mobic and HCTZ. The physician order dated 4-26-24 did not include a diagnosis for Quetiapine Fumarate. 3. Staff #1 acknowledged; the resident?s physician?s orders did not include the diagnosis for the prescribed medication.
Plan of Correction:	The RMA?s will ensure that physician or other prescriber?s orders identify the diagnosis, condition, or specific indications for administering each drug. RMA?s and administrator will monitor MAR?s and PO?s monthly and as needed. Correction Date: 7/12/2024
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation and staff interviewed, the facility failed to ensure that single-use and dedicated medical supplies and equipment shall be appropriately labeled and stored. Evidence: 1. On 6-12-24, during the medication pass observation with staff #2, resident #7?s blood sugar glucometer was observed to not be labeled. 2. Staff #2 acknowledged the resident?s blood sugar glucometer was not labeled.
Plan of Correction:	RMA?s will ensure that all dedicated medical supplies and equipment are appropriately labeled. Administrator and HCO nurse will monitor compliance with this monthly and quarterly. Correction Date: 6/12/2024
Standard #:	22VAC40-73-680-I
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the facility?s medication administration record (MAR) for a resident included all requirements. Evidence: 1. On 6-12-24, resident #1?s June 2024 MAR did not include diagnosis, condition, or specific indications for administering the following drug or supplement: (a) Amlodipine, (b) Atorvastatin, (c) Carvedilol, (d) Fluticasone, (e) Furosemide, (f) Multivitamin-Mineral, (g) Vitamin D3 and (h) Cromolyn eye drops. 2. Staff #1 and #2 acknowledged the resident?s MAR did not include diagnosis, condition, or specific indications for the drug or supplement.
Plan of Correction:	The RMA?s will ensure that physician or other prescriber?s orders identify the diagnosis, condition, or specific indications for administering each drug. RMA?s and administrator will monitor MAR?s and PO?s monthly and as needed. Correction Date: 7/12/2024
Standard #:	22VAC40-73-750-E
Description:	Based on observation and staff interviewed, the facility failed to ensure the bed linen for a resident was clean. Evidence: 1. On 6-12-24, during a tour of the facility with staff #1, the box spring cover on a resident?s bed in room #211 was observed with have light grey- and orange-colored stains. 2. Staff #1 acknowledged the box spring cover was not clean.
Plan of Correction:	Supervisors or designee will ensure all furnishings, fixtures, and equipment will be kept clean and in good repair and condition. Mattress and box-spring covers will be monitored weekly and washed or replaced if dirty or stained. Correction Date: 6/12/2024
Standard #:	22VAC40-73-870-E
Description:	Based on observations and staff interviewed, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers shall be kept clean and in good repair and condition. Evidence: 1. On 6-12-24 during a tour of the facility with staff #1, the front sink near a stall, had a slow drain. The male restroom in the common area was observed with a slow drain. The window blind in room #211 was observed to have an approximate 8 x 8-inch cutout section. The window blind in the far-right corner in room #209 was in need of repair. The commode top in the corner bathroom down the hall from the kitchen and next to the storage room, extended beyond the commode (did not fit). 2. Staff #1 acknowledged the building and equipment items needed repair.
Plan of Correction:	Supervisors or designee will ensure all furnishings, fixtures, and equipment will be kept clean and in good repair and condition. Maintenance and plumbing will correct any issues with slow draining sinks and toilet lids that become broken as they are reported to Administrator or to maintenance. Maintenance will correct any issues blinds as soon as it is reported to Administrator or to maintenance. Correction Date: 6/12/2024