VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Acadia Care LLC
9285 Critzers Shop Road
Afton, VA 22920
(434) 989-5020

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Sept. 24, 2021 , Oct. 4, 2021 and Oct. 7, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-90 The Criminal History Record Report

Comments:

A renewal inspection was initiated on September 24, 2021 and concluded on October 7, 2021. The Licensee was contacted by telephone to initiate the inspection. The Licensee reported that the current census was seven. The inspector emailed the Licensee a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, activities calendar, staff schedules, healthcare oversights, pharmacy oversights, fire and health inspections etc. submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on October 4, 2021. An exit interview was conducted with Licensee on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-310-C
Description:	Based on record review and interview with staff, the facility failed to ensure they only admitted and retained an individual as permitted by its use and occupancy classification and certificate of occupancy. Evidence: 1. The facility?s certificate of occupancy documents the facility can only accept ambulatory residents; however, Resident #2?s Report of Resident Physical Examination dated 2-10-2021 documented resident is non-ambulatory. 2. Staff #1 confirmed during interview that Resident #2 is non-ambulatory per the Report of Resident Physical Examination. Staff #1 stated Resident #2 was discharged as of date of Exit interview on 10-7-2021.
Plan of Correction:	Administrator will only accept resident?s that meet the criteria of ambulatory. A physical examination form completed and signed by a physician must indicate the resident is ambulatory prior to admission.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and interview with staff, the facility failed to ensure in accordance with ? 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: Psychotropic medications without treatment plans. Evidence: 1. Resident #1 takes 2 psychotropic medications (Clozapine and Haloperidol) as of admission on 7-08-2021; however, there was no treatment plans for the three medications. 2. Staff #1 confirmed there was no treatment plan in place for the aforementioned psychotropic medications.
Plan of Correction:	Administrator will ensure that all residents prescribed psychotropic medications have a treatment plan for use of psychotropic medications.
Standard #:	22VAC40-73-680-G
Description:	Based on record review, observation, and interview with staff, the facility failed to ensure over-the-counter medications were labeled with the resident?s name. Observation: 1. During the on-site inspection on 10-04-2021, the following resident medications were not labeled with a resident?s name: a. Bacopa monnieri b. Inositol 500 mg (2 bottles) c. Vitamin D3 125 mcg (2 bottles) d. Aspirin 81 mg 2. Staff #2 confirmed the aforementioned medications were not labeled with a resident?s name as required.
Plan of Correction:	Administrator will ensure that all medications are labeled with the individuals name including over the counter medications.
Standard #:	22VAC40-73-925-B
Description:	Based on observation and interview with staff, the facility failed to ensure common face/hand washing sinks shall have paper towels or an air dryer. Evidence: 1. The common bathroom in the hallway did not have paper towels or an air dryer for residents/non-residents use. 2. Staff #2 confirmed during inspection that paper towels or an air dryer was not made available.
Plan of Correction:	Administrator will ensure that all common face/hand washing sinks have paper towels available at all times.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview with staff, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #3?s date of hire was 3-01-2021; however, Staff #3?s criminal history record report was not completed until 8-24-2021. 2. Staff #1 confirmed Staff #3?s criminal history record report was not completed on or prior to the 30th day of employment.
Plan of Correction:	Administrator will ensure all staff have completed a background check within 30 days of hire. Record of the criminal history check will be kept in the employees record upon receipt.