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: Oct. 26, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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

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: 10-26-2023 10:23 ? 12:00 pm, 11-28-2023 12:26 ? 1:45 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview with staff, the facility failed to ensure each staff person was evaluated annually with the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #1?s date of hire is 1-01-2020. Staff did not have an annual tuberculosis risk assessment from the past year. Staff #1 confirmed during interview.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-A
Description:	Based on record review, the facility failed to ensure prior to or at the time of admission to an assisted living facility, certain personal and social information on a person shall be obtained. Evidence: 1. Resident #1 admitted 6-29-2023 according to Staff #1. The ?Patient Data Sheet? in Resident #1?s record did not contain the following information required: a. Last home address, and address from which resident was received, if different; b. Date of admission; c. Birthplace, if known; d. Marital status, if known; e. If there is a legal representative, copies of current legal documents that show proof of each legal representative's authority to act on behalf of the resident and that specify the scope of the representative's authority to make decisions and to perform other functions; f. Name, address, and telephone number of personal dentist, if known; g. Name, address, and telephone number of clergyman and place of worship, if applicable; Service in the armed forces, if applicable; h. Lifetime vocation, career, or primary role; Special interests and hobbies; i. Known allergies, if any; j. Information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable; k. Previous mental health or intellectual disability services history, if any, and if applicable for care or services; l. Current behavioral and social functioning including strengths and problems; and m. Any substance abuse history if applicable for care or services. 2. Staff #1 confirmed during interview that the information on Resident #1 was not documented in the personal and social information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the by the licensee, administrator, or his designee, and the resident or his legal representative. Evidence: Resident #2 admitted 7-23-2021. Resident #2?s ISP [undated] ISP had no signature or date from the licensee/administrator/designee, nor the resident/legal representative. The previous ISP on file was signed and dated 6-24-2022 by the legal representative of Resident #2. Resident #3 admitted 2-08-2022. Resident #3?s most current ISP did not contain a date next to the administrator or legal representative?s signatures.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-F
Description:	Based on observation and interview with staff, the facility failed to ensure the rights and responsibilities of residents were posted conspicuously in a public place in the assisted living facility. Evidence: The rights and responsibilities of residents were not posted in the facility on the date of inspection, as they were not observed during the tour on 10-26-2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-B
Description:	Based on observation and interview with staff, the facility failed to ensure bedrooms contained at least one mirror. Evidence: The bedroom occupied by Resident #1 on 10-26-2023 did not contain a mirror (nor an adjoining bathroom with a mirror). Staff #2 was present and observed on tour with licensing inspector.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and interview with staff, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: The water temperature in the bathroom at the far back hallway to the left adjoining into a bedroom (that is occupied by two male residents) had a temperature of 128?F. Staff #2 was present and acknowledged the temperature was above the required degree range.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and interview with staff, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate. Evidence: The fire and emergency evacuation drawing observed on the 10-26-2023 inspection did not show any of the required areas including primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate. Staff #2 observed along with the licensing inspector.
Plan of Correction:	Not available online. Contact Inspector for more information.