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. 8, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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

Technical Assistance:

22VAC40-73-210-F 22VAC40-73-940-A 22VAC40-73-960-B

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/08/2023. 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, and the staff schedule. Water temperature was measured, and the call bell system was monitored. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record. Evidence: 1. Staff #3?s record does not include verification that the staff person has received a copy of their current job description.
Plan of Correction:	On hire will give hob description and have them sing them. Employee has signed it.
Standard #:	22VAC40-73-440-L
Description:	Based on record review, the facility failed to maintain the completed UAI in the resident?s record. Evidence: 1. The last UAI in Resident #5?s record was dated 10/23/2020. Resident #5?s most current completed UAI dated 10/21/2022 was not maintained in the resident?s record.
Plan of Correction:	Social Worker had came to do UAI, Administrator had called for them before. Plan for Social Worker to return the UAI the same day it is done. UAI is in chart.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan include description of identified needs based upon the fall risk rating. Evidence: 1. Per progress notes, Resident #1 fell on the following days: 08/01/2023, 07/26/2023, 06/09/2023, 06/07/2023, and 05/04/2023. The fall risk ratings completed for Resident #1 following the falls indicates the ISP will address the falls of Resident #1; however, the ISP for Resident #1 dated 07/28/2023 does not address this need.
Plan of Correction:	Fall risk has been addressed on ISP now. Had gotten in place physical therapy and doctors visit for resident. Will diligently carry out to the ISP starting now.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. The last review of the rights and responsibilities of residents for Staff #1 was completed on 06/26/2022. 2. The last review of the rights and responsibilities of residents for Staff #2 was completed on 08/04/2022.
Plan of Correction:	Resident rights have been done with Staff Member #1 and #2 and have planned in-service for 8.11.23 for all staff members. Have placed on training calendar for June and December to make sure annually all staff will have resident rights reviewed.