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

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Nov. 4, 2022

Complaint Related: No

Areas Reviewed:
22VAC40-73 GENERAL PROVISIONS

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

XX 22VAC40-73 PERSONNEL

22VAC40-73 STAFFING AND SUPERVISION

XX22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

XX 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

XX 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

XX 22VAC40-73 BUILDINGS AND GROUND

XX 22VAC40-73 EMERGENCY PREPAREDNESS

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

ARTICLE 1 ? SUBJECTIVITY

32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS

63.2 GENERAL PROVISIONS

63.2 PROTECTION OF ADULTS AND REPORTING

63.2 LICENSURE AND REGISTRATION PROCEDURES

63.2 FACILITIES AND PROGRAMS

22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES

22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

22VAC40-80 THE LICENSE

22VAC40-80 THE LICENSING PROCESS

22VAC40-80 COMPLAINT INVESTIGATION

22VAC40-80 SANCTIONS

Technical Assistance:
Hose out front, trip hazard across sidewalk

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: 11-04-2022, 10:05 a.m. ? noon

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: 6
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
Observations by licensing inspector: Meal, medication pass observation, records, tour, water temperatures, fire and emergency drawing, emergency food and water, calendars (menus and activities), staff schedules, buildings and grounds tour, staff and resident records.

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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-290-A
Description: Based on observation, the facility failed to ensure any absences, substitutions, or other changes were noted on the written work schedule and included an indication of whomever is in charge at any given time.

Evidence:

1. The November 2022 written work schedule documented Staff #2 was at the facility on 11-04-2022 for the 7:00 a.m. to 7:00 p.m. shift; however, during licensing staff?s inspection on 11-04-2022 for a portion of the time frame, Staff #1 was present while Staff #2 was not present at the facility during the inspection. Staff #1 was not on the schedule for 11-04-2022.

2. The staff person in charge was not documented anywhere on the November 2022 written work schedule.

Plan of Correction: Administrator will ensure that all staff substitutions and/or absences are noted on site schedules. Lead staff will be designated for all shifts.

Standard #: 22VAC40-73-330-A
Description: Based on record review and interview with staff, the facility failed to ensure a mental health screening was conducted prior to admission when behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness and that caused concerns for the health, safety, or welfare of either that individuals or others who could be placed at risk of harm by that individual.

Evidence:

1. Resident #2 admitted 2-01-2022. Resident #2 has been in a mental health hospital prior to admission to the facility on a civil commitment around 10-28-2021.

2. Staff #2 confirmed the mental health screening for Resident #2 was not completed.

Plan of Correction: Administrator will ensure that all information required to complete a mental health screening will be gathered prior to admission and documented. Mental health assessment screening will be completed by administrator prior to admission for any individual with a pattern of behavior or behaviors that were indicative of a mental illness in the six months prior to admission.

Standard #: 22VAC40-73-440-A
Description: Based on record review and interview, the facility failed to ensure the uniform assessment instrument (UAI) was completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence:

1. Resident #1 admitted 10-19-2022. Resident #1?s UAI in the record did not contain a date of when it was completed.

2. Resident #4 admitted 7-12-2021. Resident #4?s UAI in the record was dated 7-20-2021. No more current UAI was located in the record.

Plan of Correction: Administrator will ensure that all residents have a complete UAI prior to admission, updated annually, and updated whenever there is a significant change in the resident?s condition.

Standard #: 22VAC40-73-450-C
Description: Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included the date identified of identified needs and description of needs based upon the uniform assessment instrument (UAI) and other sources.

Evidence:

1. Resident #2 admitted 2-01-2022. Resident #2?s ISP dated 2-16-2022 did not contain dates identified of the service needs. Additionally, no ADLs were identified as the resident needing assistance per the UAI dated 1-28-2022; however, the ISP documented the resident requires ?assistance and reminders to shower/bathe? and assistance with ?dressing, incontinence care, transferring, and eating as needed?.

2. Resident #4 admitted 7-12-2021. Resident #4?s ISP dated 6-24-2022 did not contain dates identified of the service needs. Additionally, no ADLs were identified as the resident needing assistance per the UAI dated 7-20-2021; however, the ISP documented the resident requires ?assistance and reminders to shower/bathe? and assistance with ?dressing, incontinence care, transferring, and eating as needed?.

Plan of Correction: Administrator will ensure that all ISP plans match the needs identified in the UAI and are dated to indicate the expected duration of need.

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 resident or his legal representative.

Evidence:

1. Resident #3 admitted 10-19-2022. Resident #3?s ISP dated 10-01-2022 was not signed by the resident or resident?s legal representative.

Plan of Correction: Administrator will ensure that all ISP plans are promptly signed by the resident or if applicable their legal representative.

Standard #: 22VAC40-73-610-C
Description: Based on record review, the facility failed to ensure the minimum daily menu met the current guidelines of the U.S. Department of Agriculture's food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences.

Evidence:

1. The menus for the week of 11-01-2022 did not meet the current guidelines as there was no fruit or vegetable offered at breakfast the mornings of 11-04-2022 or 11-06-2022. Additionally, there was no fruit or vegetable offered at lunch the afternoons of 11-04-2022, 11-05-2022, and 11-06-2022. Lastly, for dinner there was no starch offered in the evening on 11-04-2022, and no documented fruit or vegetable on 11-02-2022.

Plan of Correction: Administrator will ensure that the menu meets current guidelines from US Department of Agriculture?s food guidance system or dietary allowances of the food and Nutritional Board of the National Academy of Sciences. Each meal offered throughout the day will include a protein, fruit and/or vegetable, and starch.

Standard #: 22VAC40-73-750-B
Description: Based on observation and interview with staff, the facility failed to ensure there was an operable bed lamp or bedside light accessible to each resident.

Evidence:

1. The last room to the right with two female residents had one lamp for two residents (Bedroom 2); and

2. The first room on the right with one resident had no lamp (Bedroom 4).

3. Staff #1 observed during the tour that that was not an operable bed lamp or bedside light accessible to each resident.

Plan of Correction: Administrator will ensure that all bedrooms within the residence have a bedside lamp for each resident. Each bedroom is double occupancy so each room with have two lamps accessible to residents.

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 was maintained within a range of 105?F to 120?F.

Evidence:

1. Hot water at taps was 133.6?F in the shared hallway bathroom and was 131?F in the shared restroom of two female residents at the end of the hallway to the right (Bedroom 2).

2. Staff #1 observed the temperatures in the two restrooms that was above the required 105?F to 120?F.

Plan of Correction: Administrator will ensure all hot water taps in the residence remain within the required range of 105 degrees and 120 degrees fahrenheit.

Standard #: 22VAC40-73-960-B
Description: Based on observation, the fire and emergency evacuation drawing did not show the primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate.

Evidence:

1. The fire and emergency drawing located in Bedroom 2 only documented a red line pointing out of the facility; however, it did not document the primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate.

Plan of Correction: Administrator will ensure that all fire and emergency evacuation plans show primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers as appropriate.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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