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: March 27, 2023 , March 30, 2023 , April 6, 2023 , April 19, 2023 , May 9, 2023 and June 2, 2023

Complaint Related: Yes

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 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint An unannounced on-site complaint inspection conducted on 3-27-23, 3-30-23 and 4-6-23. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-13-23 regarding allegations in the resident care, neglect and the building. 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were not in compliance. A violation notice was issued; any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record reviewed, policy reviewed, and staff interviewed, the facility failed to ensure it reported the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 3-27-23, during the renewal inspection it was revealed that incident reports involving residents? health, safety and welfare were not reported to the licensing department. 2. On 2-21-23, resident #1?staff observed resident?s right arm to be red and swollen; resident refused to go to ER. There was no documentation of resident?s physician being notified. On 3-1-23, resident #1 was admitted to the hospital with shoulder and elbow fractures on 3-1-23. 3. Resident #2 was reported missing on 1-24-23. Resident was later located in a hospital in Petersburg Virginia. Individual reported to EMS, picking up resident three days prior in Newport News. Resident?s discharge statement, 2-25-23, noted resident ?presented to the emergency room due to recurrent seizures that were not control by the EMS crew?. On 3-20-23, the local EMT notified the facility of resident being found in a field in the community and was intoxicated and had high blood sugar. Resident was admitted to a local hospital in Newport News for seizure and hyperglycemia. 4. Resident #3 notified staff of fall on right arm on 3-2-23, resident was not seen for treatment. On 3-12-23 resident complained of right arm- not able to move arm; resident sent to local hospital and admitted. Discharge summary noted, diagnoses of fall, right elbow pain and infestation by bed bug. 5. On 1-21-23, resident #4 was reported missing to the local police station. 6. On 3-20-23, resident #5, fell to floor, right side of face, large amount of blood on floor, face, and bed. Resident continued to have seizure, 911 called, resident transported to hospital.
Plan of Correction:	An incident report training will be completed by ALFs trainer at next staff meeting. Staff members have been informed by Administrator not to repeat this violation and to report within 24 hours. Correction Date: 6/14/23
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a subsequent risk assessment for tuberculosis (TB) was completed annually on each reach as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 3-30-23, resident #1?s TB documents in the record were dated 2-7-18, 2-5-19, 1-31-20 and 3-8-21. The resident?s date of admission noted as 5-23-01. The record did not include a current risk assessment documenting the absence of TB.
Plan of Correction:	Staff will use the current screening form to ensure current risk assessments are completed annually by using the date of admission as a guideline by staff, who will monitor and report this info to whom Administrator Correction date 6/1/2023
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: 1. On 4-6-23, resident #1?s ISP dated 4-28-22 was not updated to document the resident?s significant change of condition. The ISP did not document therapy services Resident #1 was admitted to a local hospital on 3-1-23 and discharged on 3-8-23, the discharge summary noted, ?humeral head fracture, left, closed, closed fracture of right proximal humerus, forearm laceration, right, severe malnutrition, vascular dementia, underweight and contusion of front wall of thorax. ?Wound care: weekly dressing changes, may be changed sooner as needed for soiling or saturation. Please change with 4 x 4 and Tegaderm/Medipore tape or simple island dressing. Keep incision dry, no creams or lotions.? Resident also discharge with home health needs: ?physical therapy assessment -patient has weakness and decreased mobility resulting from a recent injury, illness, or surgery; occupational therapy also ordered. 2. On 3-30-23, resident #1 stated being in the hospital and had injury to shoulder and elbow. The resident stated getting dress was painful but took time- and slowly able to get dress and bath. Resident stated informing staff about an altercation with a staff member, but nothing was done. Interview with staff #4, staff not aware of any incident and provided staff with the resident?s discharge documents. 3. On 3-27-23, the inspector interviewed the occupational therapist (OT), who was at the facility. The OT stated the cause of resident?s injury was unclear; resident schedule to receive physical and occupational therapy for the fractured shoulder and elbow.
Plan of Correction:	The facility shall ensure that the ISPs will be reviewed and updated annually by administrator and staff who will monitor and report this info to administrator Correction date 6/14/2023
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the 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 medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1.On 4-6-23, resident #3?s physician?s order provided to the inspection by staff #4, did not include the diagnosis, condition, or specific indications for the following medications: (a) Cinacalcet (b) Entresto (c) Isosorbide (d) Nifedipine (e) Sevelamer Carbonate (f) Spriva Respimat and (g) Compression Stockings.
Plan of Correction:	The facility will ensure that physician or other prescriber orders identify the diagnosis, condition, or specific indications for administering each drug. Medication Aides and Administrator who will monitor and report this info to whom administrator Correction date 6/14/2023