VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Feb. 8, 2023

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 (LIs) had a discussion with the Administrator and the Director of Nursing regarding the following standard(s): 260-A

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 02/08/2023 8:50AM until 5:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: observed medication passes, activities, and noon-time meal. 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 #:	22VAC40-73-1090-A
Description:	Based on resident record review, the facility failed to ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: The Assessment of Serious Cognitive Impairment form for resident 10, dated 07/20/2021, indicates that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia; however, the form also indicates that the resident is not unable to recognize danger or protect his/her own safety and welfare.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Director of Health and Wellness and/or designee will have resident #10?s practitioner complete a new Assessment of Serious Cognitive Impairment to reflect his correct level of functioning by 2/28/23. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident Assessment of Serious cognitive impairment forms and correct with the resident?s practitioner by 3/31/23. 3. The Director of Health and Wellness and/or designee will audit all new admission?s records to verify an appropriately completed assessment of serious cognitive impairment to ensure compliance. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 resident charts and their Assessment of Serious cognitive impairment for 3 months to ensure continued compliance.
Standard #:	22VAC40-73-1100-A
Description:	Based on resident record review, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval from the approving party. EVIDENCE: The record for resident 2 contained the document, Approval for Placement in Special Care Unit, which indicated that the resident?s guardian/legal representative and independent physician give approval for resident 2 to be placed in a special care unit; however, the form was not signed and dated by either party.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Director of Health and Wellness corrected resident #2?s Approval for Placement in a Special Care Unit form by obtaining written approval from the legal guardian on 2/9/23. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident Approval for Placement forms by 3/31/23. 3. The Director of Health and Wellness and/or designee will audit all new admission?s records to verify an appropriately completed Approval for Placement in a Special Care Unit form to ensure compliance. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 resident charts and their Approval for Placement in a Special Care Unit form for 3 months to ensure continued compliance.
Standard #:	22VAC40-73-1110-A
Description:	Based on resident record review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be placed in the resident?s file. EVIDENCE: The records for resident 2 and resident 3 indicate that both residents reside in the facility?s safe, secure unit; however, neither record contained written determination and justification for appropriate placement in the special care unit by the licensee, administrator, or designee.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Administrator/Designee created a Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit and completed for Resident #2 and #3. The administrator completed new forms for all residents residing on the special care unit on 2/8/2023. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit by 2/28/23. 3. The Director of Health and Wellness and/or designee will audit all new admission?s records to verify an appropriately completed Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit to ensure compliance. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 resident charts and their Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit for 3 months to ensure continued compliance.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was reviewed and updated for a resident after a fall. EVIDENCE: The record for resident 6 contained facility staff charting notes that the resident fell on 11/22/2022, 11/30/2022 and 12/04/2022; however, the TerraBella Pheasant Ridge fall risk assessment in the record for the resident was not updated to reflect the aforementioned falls. Interview with staff 7 confirmed this was accurate.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Director of Health and Wellness will correct the ISP for resident 6 by 2/28/23. 2. The Director of Health and Wellness and/or designee will correct the TerraBella Pheasant Ridge fall risk rating assessment in resident #6?s record by 2/28/23 3. Director of Health and Wellness or designee will perform an audit of all current resident?s fall risks by 3/31/23. 4. Director of Health and Wellness or designee will educate all RMA?s and Nurses. regarding fall risk ratings tool requirement by 3/31/23 5. Director of Health and Wellness or designee will complete an audit of fall risk ratings in 10 resident records monthly for 3 months to ensure continued compliance.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required. EVIDENCE: 1. The UAI for resident 1, dated 01/06/2023, indicates that resident 1 requires assistance with toileting and stairclimbing; however, the type of assistance is not indicated on the UAI. Interview with staff 7 confirmed that resident 1 requires human help physical assistance with toileting and that the resident is unable to climb stairs. Also, the UAI for resident 1 indicates that the resident is disoriented some spheres, some of the time; however, the spheres affected are not indicated. Interview with staff 7 confirmed that the sphere affected is time. 2. The UAI for resident 10, dated 10/03/2022, indicates that resident 10 requires assistance with toileting and transferring; however, the type of assistance is not indicated on the UAI. Interview with staff 7 confirmed that resident 10 requires mechanical assistance only with toileting and transferring.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Director of Health and Wellness or designee will correct the UAI and ISP for resident #1 and #10 by 3/31/2023. 2. Director of Health and Wellness or designee will audit all resident UAI and ISPs for accuracy by 3/31/2023. 3. Director of Health and Wellness and/or designee will audit 10 resident UAI and ISPs per month for next 3 months.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all identified needs. EVIDENCE: 1. The record for the resident contained a physician?s order, dated 01/08/2023, that the resident is to be prepared and served a mechanical soft diet 3 diet; however, the ISP for resident 1, dated 02/03/2023, indicates that resident 1 is to receive a regular diet and does not include information regarding the aforementioned prescribed diet. 2. The ISP for resident 4, dated 10/11/2022, that resident 4 requires no assistance with stairclimbing and also that the resident requires mechanical and human physical assistance with stairclimbing. Interview with staff 7 confirmed that the resident does require assistance with stairclimbing. 3. The ISP for resident 7, dated 08/11/2022, indicates that resident 7 does not require any assistance when performing stairclimbing if there is an emergency; however, on the date of inspection, resident 7 was observed to be confined to a bed and would require assistance for stairclimbing in the event of an emergency.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Director of Health and Wellness or designee will correct the UAI and ISP for resident #1, #4 and #7 by 3/31/2023. 2. Director of Health and Wellness or designee will audit all resident UAI and ISPs for accuracy by 3/31/2023. 3. Director of Health and Wellness and/or designee will audit 10 resident UAI and ISPs per month for next 3 months.
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 2, dated 01/11/2023, states that this resident is receiving hospice services; however, the ISP does not indicate the types of services that hospice is providing. 2. The record for resident 7 contains the Hospice IDG Comprehensive Assessment and Plan of Care report which indicates that this resident has been receiving hospice services since 07/28/2022; however, the ISP for resident 7, dated 08/11/2022, does not indicate that this resident is receiving hospice services.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Director of Health and Wellness or designee will correct the ISP for resident #2 to reflect their current type and frequency of services provided by hospice. 2. Director of Health and Wellness or designee will correct the ISP for resident #7 to reflect that they are receiving hospice services, as well as to clarify the current type and frequency of services provided by hospice. 3. Director of Health and Wellness or designee will audit all resident ISPs for accuracy by 3/31/2023. 4. Director of Health and Wellness and/or designee will audit 10 ISPs per month for next 3 months to ensure compliance.
Standard #:	22VAC40-73-450-H
Description:	Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident. EVIDENCE: The ISP for resident 1, dated 02/03/2023, indicates that the resident is to receive round checks every two hours and will be checked on frequently for safety and toileting by care staff. Interview with staff 7 revealed that the facility does not have documentation that the rounds are being conducted by care staff for the resident.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Director of Health and Wellness or designee will correct the UAI and ISP for resident #1 to reflect his current status as an assisted living resident, without the need for 2 hour rounds. 2. Director of Health and Wellness or designee will audit all resident UAI and ISPs for accuracy by 3/31/2023. 3. Director of Health and Wellness and/or designee will audit 10 resident UAI and ISPs per month for next 3 months.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, resident record review and staff interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 11, dated 07/14/2022, indicates that the resident requires medications to be administered/monitored by a registered medication aide and/or licensed practical nurse. During on-site inspection, one licensing inspector (LI) and staff 6 noted that there was a bottle of Miralax in resident 11?s room. Resident 11 stated that she takes Miralax at least daily for constipation and that she administers it herself. The record for resident 11 did not contain a physician?s order that the resident can self-administer Miralax. Interview with staff 7 confirmed this was accurate. 2. The UAI for resident 8, dated 12/13/2022, indicates that the resident requires medications to be administered/monitored by a registered medication aide and/or licensed practical nurse. During on-site inspection, two LIs noted that there was a bottle of Extra Strength Excedrin on the resident?s table. Resident 8 stated that she self-administers this medication. The record for resident 8 did not contain a physician?s order that the resident can self-administered Excedrin. Interview with staff 7 confirmed this was accurate.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Director of Health and Wellness removed the bottle of Miralax from resident #11?s room and Extra Strength Excedrin from resident #8?s room on the date of inspection. 2. Director of Health and Wellness or designee will Inservice all-staff on appropriate items for resident rooms to ensure resident safety. Inservice to be completed by 3/31/23. 3. Director of Health and Wellness or designee will conduct random medication sweeps of 10 rooms per month for 3 months of resident?s deemed unable to self-administer medications on their UAI to ensure continued compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on observation during medication administration, resident record review and resident and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The record for resident 12 contains a uniform assessment instrument (UAI), updated on 12/22/2022 by staff 7, that the resident is no longer to self-administer medications and medications are to be administered by registered medication aides (RMAs) and/or licensed practical nurses (LPNs), a note by staff 7, dated 12/22/2022, that the resident is no longer able to self-administered medications, and a physician?s order, dated 12/22/2022, to discontinue the order for resident to self-administer medication and now medication staff will administer medications to resident 12. 2. During on-site inspection, one licensing inspector (LI) observed staff 8 administer resident 12?s medication. Resident 12 proceeded to take and swallow all the medications given to her by staff 8 except the Furosemide 20MG tablet. When the LI questioned resident 12 about why she wasn?t taking the tablet, resident 12 proceeded to inform staff 8 and the LI that she doesn?t like to take the whole Furosemide 20 MG tablet in the morning and that staff leave the pill with her. The resident stated that she cuts the pill in half herself with her pill cutter and she saves the other half of the tablet to take either later in the day or not at all. Resident 12 then went to her dresser and obtained two half tablets of Furosemide from previous days that she had not taken, and this was also observed by staff 8.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Staff # 8 contacted resident #12?s provider on 2/9/2023 to clarify Lasix 20mg 1 tab by mouth daily following two refusals of the medication as dispensed. On 2/10 Resident #12?s provider gave new orders for Lasix 10mg, 1 tab by mouth, twice daily for leg swelling. 2. Director of Health and Wellness or designee will conduct an Inservice on proper administration of medications per the 7 rights of medication administration by 3/31/23. 3. Director of Health and Wellness or designee will complete 3 random medication cart observations weekly for 3 months to ensure compliance.
Standard #:	22VAC40-73-680-K
Description:	Based on record review and observation, the facility failed to ensure that the use of PRN (as-needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed; licensed health care professionals administer PRN medication; or if medication aides administer PRN medication, the resident?s physician or other prescriber?s order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. The record for resident 10 contains physician?s orders, dated 01/10/2023, for the following PRN medications: acetaminophen 325 mg tablet ?take 2 tablets [=650 mg] by mouth every 6 hours as needed for pain/fever > 100.4. max of 3gm/24-hr-all sources?; mi-acid liquid ?take 10mls. by mouth every 4 hours as needed for heartburn?; ondansetron hcl 4 mg tablet ?take 1 tablet by mouth every 6 hours as needed for nausea/vomiting?; tramadol hcl 50 mg ?take 1 tablet by mouth every 6 hours as needed for pain?. 2. The individualized service plan (ISP) for resident 10, dated 10/03/2022, indicates that the resident resides in the facility?s memory care unit due to a diagnosis of dementia with a serious cognitive impairment and requires the assistance of a registered medication aide (RMA) or licensed practical nurse (LPN) to administer the resident?s medications. 3. Documentation on the January and February 2023 medication administration records (MARs) for resident 10 contain documentation that RMAs administered PRN medications to resident 10 on 01/13/2023, 01/14/2023, 02/05/2023, and 02/08/2023; however, the prescribed prn medications for resident 10 do not indicate what the RMAs should do if symptoms persist.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Director of Health and wellness and/or designee will complete the Documentation of physician?s or other prescriber?s oral order for PRN medication form for provider review and obtain signed orders detailing symptoms that indicate the use of the medication for all PRN medications for residents unable to determine necessity by 2/28/23. 2. The Director of Health and Wellness and or designee will perform an audit on all residents that are incapable of determining when a PRN medication is needed by 2/28/23. 3. The Director of Health and Wellness and/or designee will complete the Documentation of physician?s or other prescriber?s oral order for PRN medication form for provider review and obtain signed orders detailing symptoms that indicate the use of the medication for all PRN medications for residents unable to determine necessity by 3/31/23. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 charts of current residents unable to determine necessity of PRN medication for orders needing symptoms that indicate the use of the medication, for 3 months to maintain compliance.
Standard #:	22VAC40-73-700-2
Description:	Based on observation during a tour of the building, the facility failed to post ?No Smoking-Oxygen in Use? signs in rooms of the building where oxygen is in use. EVIDENCE: During on-site inspection, one licensing inspector (LI) observed that resident 7 was in her room receiving oxygen therapy through a concentrator; however, a ?No Smoking-Oxygen in Use? sign was not posted in the room nor on the door to the room. Also, rooms 128 and 320 were noted to have oxygen in the rooms; however, there was no sign posted in the room or on the door to the room that oxygen is in use.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Director of Health and Wellness posted No smoking signs on all resident room that contained oxygen on the date of inspection. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident charts to ensure oxygen orders and appropriate signs are in place as appropriate by 3/31/23. 3. The Director of Health and Wellness and/or designee will audit all new admission?s records and rooms for oxygen orders and supplies upon admission. 4. Director of Health and Wellness or designee will perform an audit of all rooms designated to contain oxygen monthly for 3 months to ensure proper signage.
Standard #:	22VAC40-73-860-D
Description:	Based on observation during a tour of the building, the facility failed to ensure that any operable window shall be effectively screened. EVIDENCE: During on-site inspection, one licensing inspector observed that the window at the end of the hallway on the south end of the first floor had the ability to open; however, the window was not screened.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 2/8/2023 but received 2/17/2023.. 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. During on-site inspection, one licensing inspector observed that the window at the end of the hallway on the south end of the first floor had the ability to open; however, the window was not screened. 2. Maintenance Director or designee will complete an audit of all windows and replace damaged/missing screens. Audit to be completed by 3/3/2023 and replacements ordered. Based on availability screens will be repaired or replaced by 3/31/23. 3. Audit will be completed monthly for 3 months.
Standard #:	22VAC40-73-860-G
Description:	Based on observation during a tour of the building, the facility failed to ensure hot water taps available to residents were maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. EVIDENCE: During on-site inspection, one licensing inspector (LI) measured the following bathroom sink water temperatures in the following occupied rooms: Room 127 ? 94.1 degrees Fahrenheit, Room 124 -104 degrees Fahrenheit and Room 217- 91.3 degrees Fahrenheit.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/2023 but received 02/17/2023. 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. During on-site inspection, one licensing inspector (LI) measured the following bathroom sink water temperatures in the following occupied rooms: Room 127 ? 94.1 degrees Fahrenheit, Room 124 -104 degrees Fahrenheit and Room 217- 91.3 degrees Fahrenheit. 2. Circulation pump malfunctioned during inspection. Was repair by Valley Boiler the next day. Water Temps corrected with Pump install. 3. Maintenance Director will audit Water Temperatures weekly ongoing.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. At approximately 9:42AM during on-site inspection, one licensing inspector (LI) noted that the door to room 211 was unlocked and there was a spray bottle of McKesson dermal wound cleanser sitting on the kitchen table. The bottle contained a warning to keep out of the reach of children. 2. At approximately 10:50AM during on-site inspection, the resident in room 208 was leaving her room and two LIs noted a container of Zep disinfectant spray was located on the bathroom sink and a spray bottle of Comet all-purpose cleaner was located on the table to the left of the front door. Also, at approximately 11:02AM, two LIs noted that the door to room 241 was unlocked and there was a spray bottle of Comet all-purpose cleaner located on the kitchen counter to the left of the door and a container of Lysol disinfectant spray in the resident?s bedroom. The resident located in this room was noted to be bedbound.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. The Director of Health and Wellness removed noted chemicals in room 208, 211, and 241 on the date of inspection. 2. The Director of Health and Wellness and/or designee will conduct room sweep of all resident rooms to ensure no cleaning supplies or hazardous chemicals are left unsecured. To be completed by 3/31/23. 3. Director of Health and Wellness or designee will perform a random audit of rooms weekly to ensure compliance with security of cleaning supplies and hazardous materials.
Standard #:	22VAC40-80-120-A-1
Description:	Based on document review, observation and resident record review, the facility failed to operate within the terms of its license. EVIDENCE: 1. The building evaluation, dated 04/25/2012, and the certificate of occupancy, dated 04/27/2012, for the facility indicates that the first floor of the facility, with exception to the facility?s safe, secure unit, is only permitted to house five or less non-ambulatory persons with grade level access and the facility?s second and third floors are for ambulatory persons only who do not require any assistance from anyone to evacuate the building in an emergency. The license issued to the facility, dated 09/21/2022 through 03/20/2023, indicates that floors two and three are ambulatory residents only, the safe, secure unit located on the first floor may have all non-ambulatory residents and the rest of the first floor is limited to five non-ambulatory residents. The aforementioned information was also confirmed by Collateral 1 on 02/13/2023. 2. The report of resident physical examination for resident 1, dated 01/10/2023, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. The UAI for the resident, signed by staff 6 and 7 on 01/05/2023, indicates that walking is not performed by the resident and interview with staff 7 on 02/08/2023 indicated that the resident is unable to climb stairs. The individualized service plan (ISP) for resident 1, dated 02/03/2023, indicates that the resident requires physical assistance to be escorted to the nearest exit to evacuate in the event of an emergency and that this is to be provided by activities and care staff. Resident 1 resides on the third floor of the facility. 3. The report of resident physical examination for resident 7, dated 04/20/2021, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. The ISP for resident 7, dated 08/11/2022, indicates that the resident requires verbal cues to safely evacuate in case of an emergency and that this is to be provided by direct care staff and that the resident can use the stairs in the case of an emergency with the supervision of staff. Resident 7 resides on the second floor of the facility. 4. The report of resident physical examination for resident 8, dated 12/12/2022, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. The uniform assessment instrument (UAI) for the resident, dated 12/12/2022, indicates that walking and stairclimbing is not performed by the resident. The ISP for the resident, dated 12/13/2022, indicates that the resident is to be provided physical assistance to be escorted to the nearest exit to evacuate in the event of an emergency and that this is to be provided by activities and care staff. During on-site inspection on 02/08/2023, it was noted by the licensing inspectors (LIs) during observation of the resident and resident interview that resident 8 is bed-bound and is unable to walk on her own. Resident 8 resides on the third floor of the facility.
Plan of Correction:	The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. 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. Jones, Jones & Associates Architects will be at the community on 3/2/23 to reevaluate the community. Appropriate decisions will be made once evaluation is complete.