VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ascend Health Adult Retreat
6421 Chesterfield Meadows Drive
Chesterfield, VA 23832
(804) 641-0952

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: April 19, 2021 , April 21, 2021 and April 22, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on April 19, 2021 and concluded on April 22, 2021. The director was contacted by telephone to initiate the inspection. There were 4 participants present and 2 staff. The inspector emailed the director a list of items required to complete the inspection. The Inspector reviewed 2 participant?s records and 2 staff records as well as other documentation submitted by the facility to ensure documentation was complete. A virtual tour was also conducted. 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. The Licensing Inspector has reviewed with the director/person in charge COVID-19 guidance posted on the ADCC webpage. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-61-50-B
Description:	Based on a virtual tour of the center, the center failed to ensure that the rights of participants were posted conspicuously in a public place in the center. Evidence: The rights of participants were not posted conspicuously in a public place in the center.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-50-E
Description:	Based on a review of participant records, the center failed to ensure that the rights and responsibilities of participants were reviewed annually with each participant. Evidence: The record for Participant # 1 did not contain a Participant Rights and Responsibilities form, but contained a Rights and Responsibilties of Residents in Assisted Living Facilities form dated 7-27-2020.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-230-F
Description:	Based on a review of participant records, the center failed to ensure that the preliminary plan of care and any updated plans are signed by the participant, family member, or legal representative. Evidence: -The plan of care for Participant # 1 last updated 1-28-21, was not signed by the participant, family member, or legal representative. -The plan of care for Participant # 2 last updated 1-4-21, was not signed by the participant, family member, or legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-360-B
Description:	Based on virtual tour of the center, the center failed to ensure that the menu contained snacks. Evidence: The center's menu for the month of April only contained meals but did not contain snacks.
Plan of Correction:	Not available online. Contact Inspector for more information.