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: Dec. 11, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS

Comments:

Three Representatives with the Division of Licensing conducted an unannounced, non mandated, monitoring inspection on 12/11/2019 from approximately 9:25am to approximately 12:09pm. The inspection was in reference to a facility reported incident involving a resident to resident altercation. During the inspection the facility Administrator was not available on-site. The Representatives interviewed residents and staff, tested the facility call bell system, observed the facility physical plant and photos of non-compliance were taken. Areas of non-compliance are found within this violation notice. Please complete the "plan or correction" and "date to be corrected" for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative. Please contact the facility Licensing Inspector Kimberly Rodriguez at 804-396-5696 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on a review of the medication administration record and resident record the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence #1: On 12/11/2019 with facility staff # 2 and facility consultant, resident #1's October medication administration record, evidenced an order for Divalproex Sod ER 500 MG TAB " Take 1 tablet by mouth at bedtime for mood take with 250MG to equal 750MG". According to resident #1's October medication administration record, the resident refused the medication a total of 29 out of 31 times during the month of October. Evidence #2: According to resident #1's November medication administration record, resident #1 was ordered Divalproex ER 250MG tab " Take 1 tablet by mouth at bedtime for mood take with 500MG to equal 750MG". According to resident #1's November medication administration record, resident #1 refused medication 27 out 30 times during the month of November. Evidence #3: According to resident #1's November medication administration record, resident #1 was ordered Divalproex ER 500MG tab " Take 1 tablet by mouth at bedtime for mood take with 500MG to equal 750MG". According to resident #1's November medication administration record, resident #1 refused medication November 1st through November 8th. Evidence #4: Facility staff was not able to provide documentation of notifying resident #1's physician during October or November, regarding the residents refusal for medication, prior to concluding the inspection.
Plan of Correction:	680.D. WILL BE OR HAS BEEN CORRECTED: Refusal of meds. RMA contacted the physician to get the meds discontinued or changed on 12/11/19 and 1/1/20. Med Refresher Training that was needed was corrected on 12/20/19 and 12/23/19. STEPS TO CORRECT: Training needed: One med aide had her med refresher training conducted by an LPN at another ALF on 12/20/19. The other med aides at Hilton Plaza had their med refresher training on 12/23/19 by consultant. MEASURES TO PREVENT THE NONCOMPLIANCE: The lead med aide or LPNs will randomly check the orders to ensure that physicians have been notified of the refusals, and the documentation of such notification will be on-site within one calendar week. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/OR MONITORING PREVENTATIVE: The lead med aide. They will check before exiting the building the documentation that is needed to ensure compliance with regulations. The lead med aide will contact the consultant who is an LPN with any concerns. Consultant will let the Administrative Asst. know the status of medication/medical related documentation.
Standard #:	22VAC40-73-680-I
Description:	Based on a review of resident records the facility failed to ensure the medication administration record included any medication errors or omissions. Evidence: While reviewing resident #2's medication administration record, resident #2's was ordered Hydroxyzine PAM 50MG CAP " Take 2 capsules by mouth every morning, 1 capsule at 2pm and 3 capsules at bedtime" by resident #2's physician. The record did not include any medication errors or emissions for the following administration times during the month of November: November 1, 2019 at 7:00am and 2:00pm November 5, 2019 at 2:00pm November 9, 2019 at 2:00pm November 12, 2019 at 2:00pm November 13, 2019 at 2:00pm November 16, 2019 at 2:00pm
Plan of Correction:	680.I WILL BE OR HAS BEEN CORRECTED: Med Omission. Med Refresher Training that was needed was conducted/completed on 12/20/19 and 12/23/19. STEPS TO CORRECT: Training needed: One med aide had her med refresher training conducted by an LPN at another ALF on 12/20/19. The other med aides at Hilton Plaza had their med refresher training on 12/23/19 by consultant. MEASURES TO PREVENT THE NONCOMPLIANCE: The lead med aide or LPNs will randomly check the computer and/or paper MARS if applicable when there is a glitch, and ensures that they are filed in the charts within one calendar week. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/OR MONITORING PREVENTATIVE: The lead med aide. Registered Med Aides will check before exiting shift change that the documentation needed to comply with regulations is in the chart, as well as on the MARs. The state inspector was informed by the consultant that some of the 2pm meds ?empty spaces? indicated that the meds were at the day program or documented on paper MARS. However, instead of using the printed MARS from the computer when requested, we will pull the charts of the residents to show the documentation of missing spaces not on the computerized print-outs.
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the facility physical plant, the facility failed to ensure the interior of all buildings are maintained in good repair and kept clean. Evidence #1: On 12/11/2019 with staff #1, it was observed in resident room #102 a grey substance outlined the door as evidenced by photos provided. Evidence #2: Resident room #216 floor contained multiple visible particles at the base of the walls.
Plan of Correction:	870. A. WILL BE OR HAS BEEN CORRECTED: Evidence 1. Substance outline the floor and Evidence 2. multiple visible particles were immediately cleaned on 12/11/19. Corrected on 12/11/19 less than 15 minutes after state licensing inspectors left the ALF. STEPS TO CORRECT: Shift changes will occur differently?Walk-throughs will occur at the beginning of the shift, during the shift, and at the end of the shift. Staff will report and document anything that needs cleaning. MEASURES TO PREVENT THE NONCOMPLIANCE: The lead med aides and floor supervisor will conduct walk-throughs at different times during the shift with the direct care staff to see what needs to be cleaned and ensure that it is cleaned immediately. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/ORMONITORING PREVENTATIVE: The lead med aide and/or floor supervisor. They will document what should be cleaned and alert the administrative asst. that the cleaning has been completed.
Standard #:	22VAC40-73-870-E
Description:	Based on observation of the facility physical plant, the facility failed to ensure all furnishings and showers, are kept clean. Evidence #1: The shower floor located in resident room #216 was discolored as evidenced by photos provided. Evidence#2: The smoke detector in resident room #102 did not have a cover as evidenced by photos provided.
Plan of Correction:	870. E. WILL BE OR HAS BEEN CORRECTED: Evidence 1. Shower floor?discolored and Evidence 2. Smoke detector did not have a cover. Corrected on 12/11/19 in less than 15 minutes after state licensing inspectors left the ALF. STEPS TO CORRECT: Shift changes will occur differently?Walk-throughs will occur at the beginning of the shift, during the shift, and at the end of the shift. Staff will report and document anything that needs cleaning or correcting. MEASURES TO PREVENT THE NONCOMPLIANCE: The lead med aides and floor supervisor will conduct walk-throughs at different times during the shift with direct care staff members to see what needs to be cleaned and/or corrected. The correction will be immediate. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/ORMONITORING PREVENTATIVE: The lead med aide and/or floor supervisor. They will document what should be cleaned and/or corrected and alert the administrative asst. that regulations were met.
Standard #:	22VAC40-73-930-A
Description:	Based on observation of the facility physical plant and staff interview the facility failed to ensure all assisted living facilities have a signaling device that alerts the direct care staff that the resident needs assistance. Evidence #1: On 12/11/2019 with staff #1, it was observed that resident room # 216 did not have a call bell system as evidenced by photos provided. Evidence #2: With facility staff #1 the call bell was tested in resident room #102. The call bell system in resident room #102 did not alert direct care staff. Evidence #3: While observing the second floor men's room with staff #1, it was observed that the men's restroom did not contain a call bell system.
Plan of Correction:	930-A-- WILL BE OR HAS BEEN CORRECTED: December 11, 2019 by SCATs Security System. Signal lighting device Evidence 3. A. All assisted living facilities shall have a signaling device that is easily accessible to the resident in his bedroom OR in a connecting bathroom that alerts the direct care staff that the resident needs assistance. Not needed in bathroom. Corrected on 12/11/19 within 2 hours after state licensing inspectors left the ALF by SCATs Security System. Staff members did not inform administrator that the signal lights did not work. STEPS TO CORRECT: Shift changes will occur differently?Walk-throughs will occur at the beginning of the shift, during the shift, and at the end of the shift. Staff will report and document anything that needs repairing. Signaling devices will be randomly checked at least once a month. MEASURES TO PREVENT THE NONCOMPLIANCE: The lead med aide and the administrative assistant will conduct walk-throughs at different times during shifts with the direct care staff, to see what needs to be repaired. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/ORMONITORING PREVENTATIVE: The lead med aide and the administrative assistant. They will document what is needed and will give info to the administrator. They will document what is needed and alert the administrator who will have it repaired.
Standard #:	22VAC40-73-930-B
Description:	Based on observation of the facility physical plant the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there is a signaling device that terminates at a central location that permits staff to determine the origin or is audible and visible in a manner that permit staff to determine the origin of the signal. Evidence: While searching for the facility central location of the signaling device with staff #2, it was observed that the facility signaling system that is to terminate at a central location was inoperable and staff were not able to locate the origin of the signal.
Plan of Correction:	930. B. WILL BE OR HAS BEEN CORRECTED: Signal lighting device terminating in a central location. Corrected on 12/11/19 within 2 hours after state licensing inspectors left the ALF by SCATs Security System. Staff members did not inform administrator that the signal lights did not work. STEPS TO CORRECT: Shift changes will occur differently?Walk-throughs will occur at the beginning of the shift, during the shift, and at the end of the shift. Staff will report and document anything that needs repairing. Signaling devices will be randomly checked at least once a month. MEASURES TO PREVENT THE NONCOMPLIANCE: The lead med aides and the administrative assistant will conduct walk-throughs at different times during the shift with the direct care staff to see what needs to be repaired. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/ORMONITORING PREVENTATIVE: The lead med aide and the administrative assistant. They will document what is needed and alert the administrator who will have it repaired.