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TerraBella Pheasant Ridge
4435 Pheasant Ridge
Roanoke, VA 24014
(540) 725-1120

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Nov. 30, 2022

Complaint Related: No

Areas Reviewed:
22VAC40-73 GENERAL PROVISIONS
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 PERSONNEL
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
22VAC40-73 BUILDINGS AND GROUND
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:
To ensure that the facility had a thorough understanding of the standards, the licensing inspectors and the administrator and the director of nursing had a discussion regarding standards 390-A, 1110-A and 550-F.

Comments:
Type of inspection: Monitoring
Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 11/30/2022 9:05AM through 4:00PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 5
Number of staff records reviewed: 2
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Observations by licensing inspector: audit of medication carts in the assisted living section and safe, secure unit

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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-1040-B
Description: Based on observation during a tour of the safe, secure unit, the facility failed to ensure that there were protective devices on a window in a common area accessible to residents with serious cognitive impairments to prevent the window from being opened wide enough for a resident to crawl through.

EVIDENCE:

At approximately 9:34 AM, one licensing inspector (LI) and staff 1 observed that the window on the far-right side of the dining room in the safe, secure unit did not have protective devices, and as a result, the LI was able to open the window far enough to crawl through.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

1. Protective device was added to window track to prevent windows from being opened wide enough for a resident to crawl through. Immediate correction

1. To assist with ongoing compliance, the Maintenance Director or Designee will conduct visual inspection of all bedroom and common area windows in MC to ensure all are properly secured. To be completed monthly for three months.

Standard #: 22VAC40-73-50-A
Description: Based on resident record review, the facility failed to ensure that the disclosure statement contained all required components.

EVIDENCE:

1. The record for resident 1, admitted 09/21/2022, contained a disclosure statement that did not include information on whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
2. The record for resident 2, admitted 09/21/2022, contained a disclosure statement that was not updated to include the new facility name and licensee information.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.
1. Unable to retroactively correct date of Written Disclosure for residents. ED/Designee will have Written Disclosure updated in all resident files by 1/31/2023.

2. The Executive Director will provide education for the Sales Manager, Business Office Manager or designee on regulations and completion of the Written Disclosure by 1/31/2023.

3. For on-going compliance, the Executive Director or Designee will audit 10% of resident records for Written Disclosure monthly for 3 months.

Standard #: 22VAC40-73-120-A
Description: Based on staff record review and staff interview, the facility failed to ensure a staff person received the required orientation and training in standards 22VAC40-73-120-B and 22VAC40-73-120-C within the first seven working days of employment.

EVIDENCE:

Interview with staff 3 confirmed that staff 2, date of hire 11/14/2022, has been working on the floor and staff 3 confirmed that staff 2 has not received the required orientation and training as required in standards 22VAC40-73-120-B and 22VAC40-73-120-C.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.
1. The Executive Director or designee will provide education for Business Office Manager on maintaining Record of Initial staff training as per Virginia regulations to be completed by 1/31/2023.

2. The Business Office Manager or Designee will complete audit of all current staff records for initial training completion of newly hired employees. Completed by 1/31/2023.


3. The Executive Director, Business Office Manager, or Designee will provide Initial staff training for any active associate that hasn?t completed training from 9/21/22 licensing date.


4. To assist with ongoing compliance, the Business Office Manager or Designee will audit each staff record for initial training compliance. To be completed monthly x 3 months then quarterly thereafter

Standard #: 22VAC40-73-250-D
Description: Based on staff record review and staff interview, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility prior to coming into contact with residents submitted the results of a tuberculosis (TB) risk assessment.

EVIDENCE:

The record for staff 2, date of hire 11/14/2022, did not contain the results of a TB risk assessment. Interview with staff 3 confirmed this was accurate.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

1. The Business Office Manager will have a Tuberculosis Screening completed for staff #2 by 12/31/2022.

2. The Executive Director will provide education for Business Office Manager on staff record, initial and annual tuberculosis screenings, and Virginia regulations to be completed by 1/31/2023.

3. The Business Office Manager or Designee will audit all current staff records for initial tuberculosis screening to be completed by 1/31/2023.

4. To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff record for initial tuberculosis screening once a month for three months. Complete by 3/30/23

Standard #: 22VAC40-73-310-B
Description: Based on resident record review and staff interview, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the potential resident and his legal representative was conducted.

EVIDENCE:

The records for resident 4, admitted 10/29/2022, and resident 5, admitted 10/19/2022, lacked evidence of a documented interview between the administrator or a designee responsible for admission and retention decisions and the aforementioned residents and their legal representatives. Interview with staff 3 confirmed this was accurate.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

1. Executive Director or Designee will create an Admissions Interview form and put into place for all new admissions. Complete by 1/31/23.

2. Executive Director or Designee will provide education to the Marketing director on completing Admissions Interview prior to resident admission by 1/31/20223.

3. Unable to retroactively correct date of Admissions Interview for resident number four. Admission Interview document will be completed for each resident admitted since 9/1/2022 by Marketing Director/ Designee. Completion by 1/31/2023.

Standard #: 22VAC40-73-320-A
Description: Based on resident record review and staff interview, the facility failed to ensure the physical examination required within the 30 day preceding admission for a resident contained all the required components.

EVIDENCE:

The report of resident physical examination for resident 4, dated 10/28/2022, lacked the following required information: if the resident has gastric tubes, if the resident presents imminent physical threat or danger to self or others and/or if the resident requires continuous licensed nursing care. Interview with staff 3 confirmed that the facility did not have this information available at the facility during on-site inspection.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.
1. Director of Health and Wellness will obtain the documentation needed for resident #4 by 12/31/2022.

2. Director of Health and Wellness or designee will audit all new admissions for required components since licensing on 9/21/22 to ensure compliance. Complete 1/22/2023

3. Director of Health and wellness or designee will review history and physical forms prior to admission to ensure required documentation is complete. Immediate

4. Director of Health and wellness or designee will audit 10 resident History and Physical forms per month for 3 months to maintain compliance. Complete 3/30/23

Standard #: 22VAC40-73-325-B
Description: Based on resident record review and staff interview, the facility failed to review and update the fall risk rating for a resident after the resident had fallen.

EVIDENCE:

The uniform assessment instrument (UAI) for resident 5, dated 10/06/2022, indicated that the resident is assisted living level of care.
Doctor?s progress notes in the record for resident 5, dated 11/01/2022; 11/14/2022 and 11/22/2022, all indicated that the doctor was visiting the resident due to falls; three in total; however, the most recent fall risk rating in the record for the resident was dated 10/19/2022. Interview with staff 4 confirmed that the fall risk rating for the resident has not been reviewed and updated to reflect the past three falls.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.
1. Director of Health and Wellness or designee will correct the ISP for resident 5 complete by 12/30/2022.

2. The Executive Director (ED) or designee will provide education for the Health and Wellness Director and/or designee on fall risk ratings by 1/31/2023.

3. The Health and Wellness Director or designee will perform an audit of all current residents' fall risk ratings. Completed by 1/31/2023.

4. To assist with ongoing compliance, the Health and Wellness Director or designee will randomly audit current residents' fall risk ratings once a month for three months.

Standard #: 22VAC40-73-350-B
Description: Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.

EVIDENCE:

The records for resident 4, admitted 10/29/2022, and resident 5, admitted 10/19/2022, did not contain documentation that a registered sex offender search was conducted for either resident. Interview with staff 3 confirmed this was accurate.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.
1. The Executive Director, Business Office Manager or Designee will ascertain sex offender screening and results for resident 4 and resident 5 are completed by 1/31/2023.

2. The Executive Director or designee will provide education for Business Office Manager and Sales Director on resident sex offender screening and obtaining results prior to admission per Virginia regulations. Complete by 1/31/2023.

3. The Business Office Manager or Designee will perform an audit of current resident records for sex offender screening and results. Complete by 1/31/2023.

4. Business Office Manager or Designee will audit all new resident records for sex offender screening and results monthly for 3 months to maintain compliance

Standard #: 22VAC40-73-410-A
Description: Based on resident record review and staff interview, the facility failed to ensure an acknowledgment was signed and dated that an orientation for new residents and their legal representatives including emergency response procedures, mealtimes, and use of the call system was provided upon admission.

EVIDENCE:

The records for resident 1 and 2, admitted 09/21/2022, and resident 5, admitted 10/19/2022, lacked documentation that both residents and their legal representatives received orientation. Interview with staff 3 confirmed this was accurate.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective

1. Executive Director, Sales Director or Designee will develop and implement resident orientation into contract signing by 1/31/2023.

2. Sales Director or designee will complete Resident Orientation with Resident #5 by 12/31/2023 and place documentation in resident file.

3. Business Office Manager or designee will audit all resident files for resident orientation.

4. Business Office Manager or designee will give all residents admitted from 9/21/2022 forward the resident orientation information and place documentation in resident file. Complete 1/31/23

5. Executive Director will educate Business Office Manager and Sales Director on the DSS Standard requirement for Resident Orientation. Complete 12/31/22

6. Business Office Manager or designee will review each resident file at time of admission for compliance. An audit of all residents admitted from 9/21/2022 to current day will be completed.by 1/31/23

Standard #: 22VAC40-73-640-A
Description: Based on observation during medication cart audits and staff interview, the facility failed to ensure the medication management policy was implemented.

EVIDENCE:

The Insulin Glargine insulin pen that was located on the medication cart for resident 6 did not contain the date in which staff opened the insulin pen for the resident, this was also observed by staff 4 and 7.

During interview with staff 4, even though it is not stated in the facility?s medication management plan provided during on-site inspection, staff 4 stated that staff are to write open dates on medications that have expiration dates once they are opened.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.
1. Director of Health and Wellness or Designee will complete Medication Cart Audit on each medication cart by 1/31/2023.

2. DHW or Designee will provide education for nurses and RMAs on reviewing medications expiration dates and documenting date medication is opened on label. Completed by 1/31/22/2023.


3. To assist with on-going compliance; Director of Health and Wellness or Designee will conduct weekly med cart audits. Ongoing to maintain compliance

Standard #: 22VAC40-73-860-I
Description: Based on observation during a tour of the safe, secure unit, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area.

EVIDENCE:

At approximately 9:30 AM, one licensing inspector (LI) and staff 1 noted that the door to the housekeeping closet was unlocked. The LI and staff 1 observed the following cleaning supplies on shelves within the housekeeping closet: Windex Multi-Surface Disinfectant Cleaner, Swiffer Wet Jet cleaning liquid, ECOLAB Miracle Spotter spray, D-STROY morning fresh spray, Monogram Disinfectant Bleach, Neutral Disinfectant Cleaner, as well as ECOLAB Disinfecting Acid Bathroom Cleaner and Peroxide Multi-Surface Cleaner and Disinfectant dispensers on the wall.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

1. Maintenance Director immediately removed blockage from doorway and secured door. Immediate correction
2. Maintenance Director has ensured automatic closer is functioning correctly and door is locked. Immediate correction

3. Maintenance Director/Designee will audit housekeeping closets weekly for 3 months then monthly thereafter to ensure all self-closing doors are closing, locking, and functioning correctly.

Standard #: 22VAC40-73-870-A
Description: Based on observation during a tour of the building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.

EVIDENCE:

1. While performing a walk-through of the memory care unit at 9:24 AM, one licensing inspector (LI) and staff 1 observed that the flooring at the threshold to room 177 was missing which created a gap in the flooring of the doorway.
2. One LI and staff 1 made the following observations in the memory care unit: dark scuffs across the lower portion of walls in the hallways and on the front of resident room doors; and the baseboard paint across from room 168 was chipped.
3. At approximately 10:00 AM, one LI observed that the walls throughout the dining room in the assisted living area had long scuffs and areas of dripping stains on the wall on the right side of the dining room.

Plan of Correction: The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

1. Rubber Threshold at Doorway of RM 177 was cleaned and glued back in place on 11/30/22. Immediate Correction

2. Executive Director or designee will provide education for Maintenance Manager and Maintenance Technician on Maintenance of interior to be kept in good repair by 1/31/2022.

3. Removal of wallpaper, new paint for all hallways and trim thru out Memory Care by 1/31/2023. RM 168 baseboard will be repaired and painted. Contractor scheduled to start work on 12/13/2023.

4. Maintenance Director or designee will touch up scuffs and paint in Assisted Living Dining room by 1/31/2023.

5. To assist with ongoing compliance, the Maintenance Director or Designee will conduct visual inspection of all public areas to ensure building is maintained in good repair once a month for three months.

Standard #: 22VAC40-90-30-B
Description: Based on staff record review, the facility failed to ensure that the sworn disclosure statement was completed for all applicants for employment.

EVIDENCE:

Staff 6 through 28, all with a date of hire of 09/21/2022, contained a sworn disclosure statement that was either not completed for the new licensee which was established on 09/21/2022 or was completed after employee with the new licensee.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

? The Executive Director/designee will provide education for Business Office Manager on sworn disclosure statements and Virginia Regulations. Complete by 1/31/2023.

? The Business Office Manager or Designee will audit all current staff records for sworn disclosure statements. Complete 1/31/23.

? Business Office Manager/ Designee to have New Sworn Disclosure Statements completed for all staff as required for licensing on 9/21/22. Complete by 1/31/23

? Business Office Manager or Designee will audit all new staff records for sworn disclosure statements monthly for compliance.Ongoing

Standard #: 22VAC40-90-40-B
Description: Based on staff record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.

EVIDENCE:

The record for staff 2, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 11/10/2022.
The record for staff 9, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 12/07/2020.
The record for staff 11, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 05/22/2022.
The record for staff 18, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 12/21/2021.
The record for staff 22, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 12/05/2016.
The record for staff 26, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 09/29/2021.
The record for staff 27, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 06/11/2020.

Plan of Correction: The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective.

? The Executive Director or designee will provide education for Business Office Manager on Criminal History Records and Virginia regulations to be completed by 1/31/2022.

? The Business Office Manager or Designee will audit all current staff records for Criminal History Records to be completed by 1/31/23.

? New Criminal History Records will be run for anyone with a date prior to 9/21/22.

? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records and once a month for three months Complete 3/30/23.

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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