VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Nov. 18, 2024

Complaint Related: No

Areas Reviewed:

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 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/24 from 9:30 am to 2:30 pm. 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: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity was observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility did not ensure the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. The ISP for Resident #1, developed 4/5/24, was revised on 6/10/24 and on 9/18/24 was not signed and dated by the resident, or their legal representative. 2. Staff #4 acknowledged the resident #1?s ISP did not include required signatures by the resident, or their legal representative.
Plan of Correction:	Administrator called and emailed the POA to sign the updated areas of ISP. I will send and call after I have any updates or changes ISP as soon as its done and have POA sign. S.Davis RMA will check ISP monthly behind me to make sure they are signed and families have followed up.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, a review of the facility?s medication plan and interview, it was determined that the facility shall have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include A plan for proper disposal of medication. Evidence: 1. During the medication cart inspection, Farxiga 10mg tabs for resident #5 were found with an expiration date of 04/11/24. 2. Staff #2 confirmed the medication for resident #5 was expired.
Plan of Correction:	S.Davis RMA removed medication out of drawers and destroyed per policy. We Called the family and physician and it was reordered new sent to us. When family brings in RX will send to pharmacy to be repackaged each time. We will Check cart every Monday checking dates closely Admin will follow up each week.