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: Jan. 4, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Technical Assistance:

All admission paperwork including personal data completion needed each resident

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-04-2023, 10:52 a.m. ? 11:15 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12-21-2022 regarding allegations in the area(s) of: Administration and Administrative Services; Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 7 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Records, interviews An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident #1 admitted 11-17-2022 per the Resident Agreement. An ?Incident Report Form? dated 12-19-2022 documented at an incident at 8:55 p.m., ?[Resident #1] came down the hallway [Resident #1] walked briskly threw(sic) the common area walked around the table when passing [Resident #2] [Resident #1] pulled [Resident #2]?s stocking hat off and continue to jog to the hallway [Resident #2] jumped up and hit [Resident #1] in the face...? 2. Resident #1?s ?ED After Visit Summary? dated 12-20-2022 documented Resident #1 had a diagnosis of ?Closed fracture of left orbital floor, initial encounter? from the incident that occurred on 12-19-2022 as confirmed by Staff #1. 3. Additionally, an ?Incident Report Form? dated 12-31-2022 documented, ?At approximately 12:30 p.m., [Resident #1] exited [Resident #1?s] room, went into the kitchen and grabbed a metal grate from the stove. [Resident #1] use the grate to hit and destroy a laptop and attempted to hit a staff member with it. Staff got the grate away?? 4. Staff #1 conformed an incident report was not sent to the regional licensing office within 24 hours of the major incident involving Residents #1 and #2 on 12-19-2022 or 12-31-2022.
Plan of Correction:	Administrator will ensure all incident reportable events of major incidents which negatively affect or threaten the life, health, safety, welfare of any resident are reported to the licensing agent within 24 hours. Staff will directly inform administrator of all incident reportable events and administrator will notify licensing office by text or email.