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: Jan. 28, 2022

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 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted by licensing staff from 10:30 a.m. to 12:40 p.m. A census of 5 participants was reported. A sample of 4 participant records and 3 staff records were reviewed. A tour of the center was conducted, facility postings were observed, and center documentation was reviewed. The lunch meal was also observed. The violations cited are identified in this report. 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 #:	22VAC40-61-140-B
Description:	Based on a review of staff records the center failed to ensure that all staff who do not meet one of the requirements at the time of employment successfully meet one of the direct care requirements within two months of employment. Evidence: Record for Staff # 2 (date of hire: 3-10-2020) did not contain documentation of direct care qualifications within two months of employment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-140-D
Description:	Based on a review of staff records the center failed to ensure that direct care staff employed by the center prior to December 29, 2019, who do not meet one of the requirements at the time of employment do so by December 20, 2020. Evidence: The record for Staff # 3 (date of hire: 4-15-19) did not contain documentation of direct care qualifications by 12-20-2020.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-160-A-1
Description:	Based on a review of staff records the center failed to ensure that each staff person maintain current certification in first aid. Evidence: -The record for Staff # 3 (date of hire: 4-15-2019) contained first aid certification that expired on 7-27-21. -The record for Staff # 2 (date of hire: 3-10-2020) did not contain first aid certification at all.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-330-G-5
Description:	Based on on-site observation of the center's postings the center failed to ensure that the current month's activity schedule was posted. Evidence: The activity schedule posted was for the month of December 2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-2
Description:	Based on on-site observation of the center's postings the center failed to ensure that the most recent violation notice was posted. Evidence: The center's most recent violation notice was not posted and a Provider Risk Performance Profile was posted instead.
Plan of Correction:	Not available online. Contact Inspector for more information.