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. 6, 2023

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 GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 SANCTIONS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 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:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-6-23 from 9:20 a.m.- 12:25 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants 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 participant records reviewed: 4 Number of staff records reviewed: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit supplies, participant activities. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-61-130-C
Description:	Based on a review of staff records the facility failed to ensure that the director shall complete 24 hours of continuing education training annually to maintain and develop skills. Evidence: The record for the director did not contain documentation of 24 hours of current annual training. The last training documented in the record was in 2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-150-A
Description:	Based on a review of staff records the center failed to ensure that annual training included at least two hours of infection control and prevention training. Evidence: Three of three staff records reviewed did not contain documentation of current training hours that included two hours of infection control and prevention training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-180-E-1
Description:	Based on a review of staff records, the center failed to ensure that each staff person shall obtain initial tuberculosis (TB) examination and report. Evidence: The record for Staff # 1 (date of hire: 11-6-19) did not contain documentation of an initial TB screening
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-180-E-2
Description:	Based on a review of staff records, the center failed to ensure that each staff person shall obtain initial tuberculosis (TB) examination and report. Evidence: The record for Staff # 1 (date of hire: 11-6-19) did not contain documentation of an initial TB screening
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-260-B
Description:	Based on a review of participant records the center failed to ensure that the report of the required physical examination contained all required items. Evidence: The record for Participant # 1 (admit date: 9-8-22) contained a Veterans Administration Medical Documentation form that did not include the following required items: height, weight, blood pressure, any known allergies and description of the person?s reactions, a statement that specifies whether the individual is considered to be ambulatory or nonambulatory, a statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-520-C
Description:	Based on a review of facility documentation, the facility failed to ensure that the center conduct the semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers. The review shall be documented by signing and dating. Evidence: The facility did not have documentation of the semi-annual review of the emergency preparedness and response plan.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-550-A
Description:	Based on a review of the center?s first aid kit the center failed to ensure that the first aid kit contained all required items. Evidence: The first aid kit did not contain the following items: bee sting swabs or preparation, ice pack or ice bag.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-1
Description:	Based on observation of the center's postings, the facility failed to ensure that the most recent violation notice was posted. Evidence: The center's most recent violation notice was not posted.
Plan of Correction:	Not available online. Contact Inspector for more information.