VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Eugene H. Bloom Retirement Center
308 Weaver Avenue
Emporia, VA 23847
(434) 348-4004

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Aug. 21, 2019 and Aug. 22, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced renewal inspection was conducted on August 21, 2019 from 9:39 a.m. to 5:15 p.m. and August 22, 2019 from 8:45 a.m. to 12:25 p.m. There were 35 residents in care. The following was discussed during the inspection: Resident rights, notifications to licensing office, emergency supplies, storage of resident furniture and maintenance supplies, and resident laundry and fees. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-B
Description:	Based on observation and interview, the failed to ensure the current license was posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. The license was not posted anywhere in the facility on 08-21-19 during tour of the facility with staff #2. 2. Staff #1 observed and confirmed the license was not posted in the facility.
Plan of Correction:	We had redecorated building It was on the desk It was put up that day 8.21.19 Will have on wall in full view of all family and visitors as required by regulation Will checked monthly per Assisted admin that all licenses are updated and kept posted as required
Standard #:	22VAC40-73-190-A
Description:	Based on observation and interview, when the administrator is not on duty on the premises, there was a designated direct care staff in charge on the premises. Evidence: 1. On 08-22-19 upon arrival, the administrator was not present at 8:45 a.m. as she was scheduled to be off. When asked who was in charge, staff #3 stated staff #2 was in charge during the administrator?s absence; however, staff #2 was not present. 2. Consequently, staff #2 arrived at the facility approximately 30 minutes later.
Plan of Correction:	Talked to staff after inspections their knowledge is to say they are in charge of building to admin or assist admin comes in. RMA is in charge on schedule. An inservice was done 9.20.19 with staff about in charge person and who is the in charge of building to reinforce the regulation
Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview, the facility failed to ensure each staff person required to be evaluated annually for tuberculosis submit a risk assessment, documenting that the individual is free of tuberculosis in a communicable form. Evidence: 1. Staff #3?s date of hire is 05-01-17. The most recent tuberculosis screening on file was dated 06-08-2018, as observed during record review on 08-21-19. 2. Staff #1 observed and confirmed the annual tuberculosis risk assessment was not evaluated annually for staff #3.
Plan of Correction:	Administrator will make monthly reviews of TB of staff due. At end of each month assisted administrator will recheck and make sure they are done and on their files 8.31.29
Standard #:	22VAC40-73-325-B
Description:	Based on observation and interview, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. During record review on 08-22-19, Resident #1 ?Resident care notes? documented on 02-17-19 the following: ?Resident fell in hallway by kitchen door; resident has small hematoma on back of head??. 2. There was no fall risk rating completed for resident #1 after the documented fall on 02-17-19. 3. Staff #2 observed and confirmed that no fall risk rating was completed after the fall on 02-17-19.
Plan of Correction:	Review policy and regulation Each time a fall occurs a fall risk rating will be done Admin and nurse will check each month to review falls and make sure risk and ISP is updated started 8.23.19
Standard #:	22VAC40-73-440-D
Description:	Based on record review and interview, the facility failed to ensure for private pay individuals, the uniform assessment instrument (UAI) was completed as required by 22 VAC 30-110. 1. During record review on 08-21-19, Resident #2 was admitted 08-02-19. The most current UAI dated 08-02-19 was not signed by the staff who completed the assessment. 2. Staff #1 observed and confirmed the UAI was not signed and that she had completed the UAI for resident #2.
Plan of Correction:	Administrator corrected and signed during the inspection 8.21.19 The administrator will make ongoing reviews and make sure all UAI?s are signed. The nurse will follow up and check end of month on the monthly updated UAI?s are signed correctly in place
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified, a written description of what services will be provided to address identified needs, when and where the services will be provided, the expected outcome and time frame for expected outcome, and date outcome achieved. Evidence: 1. During record review on 08-21-19, Resident #3 was admitted 11-01-18. The most current ISP dated 11-01-18 included the resident?s allergies, but did not identify a description of identified needs, date identified, a written description of what services will be provided to address identified needs, when and where the services will be provided, the expected outcome and time frame for expected outcome, and date outcome achieved. The record did not contain any additional ISPs. 2. Staff #1 observed and confirmed resident #3?s ISP did not include a description of resident?s allergies.
Plan of Correction:	1. Corrected ISP since inspection and dated , The administrator and nurse will make an ongoing reviews of ISP to ensure accurately needs are addressed and outcomes are put in place. 2. Resident #3 allergies were placed on ISP 8.23.19 addressed and expected outcomes were put in place. The administrator and nurse will make ongoing reviews of ISP to ensure accuracy
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. During the facility tour with staff #1 and staff #2 on 08-21-19, the following was observed: a. In the ?Ward? hallway by the exit sign, there was a ceiling tile that was dark brown stained and buckling that spanned approximately two feet in diameter; and b. In the ?Semi-Private? hallway above the nurses? station, there was a semi-circle shaped brown stain approximately 4 inches long on a ceiling tile. 2. Staff #2 observed and confirmed the stains in the ?Semi-Private? hallway shower room. Staff #1 observed and confirmed the stains on the ceiling tiles in the ?Ward? and ?Semi-Private? hallways.
Plan of Correction:	Maintenance corrected on inspection and put new tiles up in all areas 8.21.22.19 Added to maintenance weekly list to check tiles each week and change out if any stains Admin and assist admin make rounds each morning and will check to make sure tiles are clean and stain free and document on maintenance list Also explained the importance of replacing as soon as he sees them with a small stain.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview, the facility failed to ensure all equipment was in good repair. Evidence: 1. During the facility tour with staff #2 on 08-21-19, the following was observed: a. Room 5 and Room 28 had portable window air conditioning units sitting on the floor near the window. The open window space was covered with a tarp. 2. Staff #2 stated ?The units are broken and being replaced.?
Plan of Correction:	we had ordered our units a few week before and they were delayed No client needed the room. In this event we will notified licensing about needing a few more weeks for units to come in and leave old unit in place. To let you know we can?t use rooms until units come in. Replaced 9.28.19
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview, the facility failed to ensure the fire and emergency evacuation drills record included the number of residents that participated nor any special conditions simulated. Evidence: 1. On 08-21-2019 during record review, the fire and emergency evacuation drill forms dated 01-31-19, 02-28-19, 03-31-19, 04-29-19, 05-31-19, 06-29-19, and 07-28-19 did not include the number of residents that participated nor any special conditions simulated. 2. Staff #1 observed and confirmed the number of residents that participated nor any special conditions simulated were not documented on the forms.
Plan of Correction:	Administrator went over regulation with Maintenance about fire and safety and how to correctly complete the fire drill form, about the importance of doing special conditions and correct number of residents in place. Maintenance and administrator did last fire drill August 30,2019. Administrator will check each month to make sure fire drill documentation is being done correctly
Standard #:	22VAC40-73-980-C
Description:	Based on observation and interview, the facility failed to ensure the first aid kit was checked at least monthly to ensure that all items are present and items with expiration dates were not past their expiration dates. Evidence: 1. During review on 08-21-2019, the first aid kit contained hand sanitizer with an expiration date of September 2017. 2. The last monthly check of the first aid kit was dated February 2019 according to the facility?s log used by staff. 3. Staff #1 observed and confirmed the expired item in the first aid kit and the last monthly check was February 2019.
Plan of Correction:	Sanitizer was replaced same day First Aid kIt was check 8.30.19 Admin Will assign a staff member each month and Admin will check social services book end of month to make sure it has been done 8.30.19 started