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: Oct. 15, 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

Comments:

Type of inspection: Monitoring An on-site non-mandated monitoring inspection was conducted on 10-15-24 (Ar 07:38 a.m/ Dep 13:20 p.m.) 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. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: breakfast meal, water temperature, first aid kit Additional Comments/Discussion: 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 #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medical condition without a diagnosis and treatment. Evidence: 1. On 10-15-24, resident #4?s October 2024 medication administration record (MAR) and prescriber?s order fax dated 6-20-24 noted resident prescribed Aripiprazole (Abilify) and Benztropine (Cogentin). The resident?s record did not include a psychotropic treatment plan for this psychotropic medication. 2. Staff #1 acknowledged the residents? record did not include a psychotropic treatment plan for the prescribed psychotropic medication.
Plan of Correction:	LALFA will be responsible for monitoring psychotropic treatment plans for all existing and new psychotropic medications. Date to be corrected: 10/21/2024
Standard #:	22VAC40-73-450-F
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 10-15-24, resident #4?s uniformed assessment instrument (UAI) dated 8-19-24 noted resident needed assistance with bathing. The narrative in the document noted resident required supervision with bathing. Staff #2 stated resident required verbal prompting/reminders for bathing and sometimes physical assistance. The individualized service plan (ISP) dated 8-19-24 did not include this assessed need. 2. Staff #1 acknowledged the resident?s ISP did not include all assessed needs.
Plan of Correction:	LALFA and Supervisor of staff or designee will ensure that the individualized service plan (ISP) will be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Date to be corrected: 10/21/2024
Standard #:	22VAC40-73-680-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN (as needed) medication when the facility has obtained from the resident?s physician or other prescriber a detailed medical order, the order included all required information. The order shall include the symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period and directions as to what to do if symptoms persist. Evidence: 1. On 10-15-24, during the medication pass observation with staff #3, resident #7?s prescribed PRN Naloxone noted nasal spray may be given every 2-3 minutes until assistance arrives. 2. Staff #1 and #3 acknowledged the PRN dosage was every 2-3 minutes and not exact time.
Plan of Correction:	RMA?s will not accept orders that do not have specific directions. Date to be corrected: 10/21/2024
Standard #:	22VAC40-73-680-M
Description:	Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 10-15-24, following medication pass observation with staff #3, the prescribed PRNs noted on resident #3?s physician?s orders dated 8-29-24 were not available. Ondansetron (Zofran) and Hydrocortisone cream were not available in the facility. 2. Staff #1 and #3 acknowledged resident #3?s PRN s were not available in the facility.
Plan of Correction:	RMA?s will audit carts monthly to ensure that all PRN?s are available. Date to be corrected: 10/21/2024
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 10-15-24 during a tour of the facility with staff #2, the water temperature at the faucet in the bathtub in the tub room on the first floor near the laundry room at 12:40 p.m. was 91.9. 2. Staff #2 acknowledged the water temperature in the tub room on the first floor was not within the required range.
Plan of Correction:	Supervisor of staff will ensure that hot water taps available to residents will be maintained within a range of 105 degrees to 120 degrees F. Date to be corrected: 10/21/2024