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: Jan. 23, 2024

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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2024 8:16AM until 4:09PM 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, medication cart audit, and meals 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 #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. EVIDENCE: The record for staff person 1 who is a direct care staff member, date of hire 11/15/2023, did not include evidence that this staff person has received certification in first aid. Interview with staff person 5 confirmed that staff person 1 does not have first aid certification.
Plan of Correction:	The Executive Director (ED) or designee will perform an audit of all employee files to ensure all staff have first by 2/17/2024. First aid and CPR class will be scheduled by 2/29/2024
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, all residents of assisted living facilities (ALF) shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110-30-F) which includes that the UAI shall be completed annually on all individuals residing in an ALF. EVIDENCE: 1. During an on-site inspection on 1/23/2024, the record for resident 6 contained a UAI dated 12/22/2022. 2. During an interview with two Licensing Inspectors (LIs) and staff person 5, staff person 5 revealed the UAI, dated 12/22/2022, in the record for resident 6 is the most recent UAI completed for the resident.
Plan of Correction:	ED or designee will perform 100% chart audit for annual UAI dates on 2/29/24. Any UAI out of compliance will be completed immediately.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission. EVIDENCE: 1. During an on-site inspection on 01/23/2024, the record for resident 1 indicated the resident was admitted to the facility on 12/22/2023 and the record for resident 3 indicated the resident was admitted to the facility on 12/05/2023. The records for residents 1 and 3 did not contain a comprehensive ISP. 2. During an interview with two licensing inspectors (LIs) and staff person 5, staff person 5 revealed that a comprehensive ISP had not been completed for residents 1 and 3.
Plan of Correction:	ED or designee will perform 100% chart audit of all resident files to ensure the ISP has been completed within 30 days of admission by 2/29/24 Any ISP found missing will be completed immediately.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months. EVIDENCE: 1. During an on-site inspection on 1/23/2024, the record for resident 6 contained an ISP dated 12/22/2022. 2. During an interview with two Licensing Inspectors (LIs) and staff person 5, staff person 5 revealed the ISP, dated 12/22/2022, in the record for resident 6 is the most recent ISP completed for the resident.
Plan of Correction:	ED or designee will complete 100% chart audit of ISP?s to ensure they have been reviewed and updated at least every 12 months by 2/29/24. Any ISP?s out of compliance will be updated immediately.
Standard #:	22VAC40-73-640-A
Description:	Based on an audit of facility medication carts, staff interview and facility policy review, the facility failed to ensure the medication management plan (MMP) shall address procedures for administering medication which includes methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. During an audit of the memory care medication cart, two licensing inspectors (LI) observed an opened Novolog insulin pen in the top drawer for resident 11. Manufacturer?s instructions for Novolog indicate that once this insulin pen is opened it expires in 28 days. The Novolog insulin pen did not contain information of when the pen had been opened. 2. Interview with staff person 6 revealed that she was not the staff person who put the insulin pen in the medication cart and was unsure of when it had been opened and indicated that she had used the Novolog insulin pen on 01/23/2024 for resident 11 during the morning medication administration. 3. The MMP, dated 7/1/2021, provided by staff person 5 during on-site inspection as the facility?s current MMP, did not include a method to prevent the use of outdated, damaged, or contaminated medications.
Plan of Correction:	ED or designee will perform 100% med cart audit to ensure all bulk medications have open dates and/or expiration dates by 2/17/24. Any medications found to be out of compliance will be discarded immediately. New Medication Management plan put into place 2/1/24 and will be sent to licensing by 2/2/24.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. Resident 3 was admitted to the facility on 12/05/2023. 2. The record for resident 3 includes an electronically signed progress note from Collateral 2, dated 12/07/2023, that Collateral 2 noted polypharmacy and is discontinuing the resident?s prescribed fish oil, multivitamin, vitamin C and Protonix. The record for the resident also includes a signed order, dated 12/07/2023, that contains the same information. 3. The December 2023 medication administration record (MAR) for resident 3 includes documentation that the resident was administered the aforementioned medications and that these medications were not discontinued per the signed physician?s order. 4. The January 2024 MAR for resident 3 includes documentation that the resident was administered fish oil, multivitamin, and vitamin C from 01/01/2024 through 01/23/2024 and Protonix was administered from 01/01/2024 through 01/11/2024.
Plan of Correction:	ED or designee will perform 100% MAR audit, Comparing MAR and Printed orders to ensure they match. By 2/29/24. ED or designee will in-service all clinical staff on New 4 bin order system by 2/17/24.
Standard #:	22VAC40-73-930-D
Description:	Based on resident record review and facility documentation review, the facility failed to ensure to document rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds, for each resident with an inability to use the signaling device. EVIDENCE: 1. The individualized service plan (ISP) for resident 9, dated 03/10/2023, and the ISP for resident 10, dated 03/27/2023, both indicate that residents 9 and 10 have an inability to use the signaling device and that both residents will have two-hour rounds to monitor for emergencies or other unanticipated needs. 2. The rounding logs reviewed for both residents 9 and 10 during on-site inspection contain numerous days during January 2024 that do not contain documentation of the staff person(s) who preformed rounds on residents 9 and 10.
Plan of Correction:	ED or designee will perform daily audits of 2 hour round sheets to ensure rounds are being completed by 2/5/24. ED or designee will perform 100% ISP audit of residents that have an inability to use the signaling device to ensure it is on the ISP by 2/17/2024
Standard #:	22VAC40-73-950-E
Description:	Based on staff interview, the facility failed to ensure to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers and shall be documented by signing and dating. EVIDENCE: During on-site inspection on 01/23/2024, staff person 5 was unable to produce evidence that a semi-annual review of the facility?s emergency preparedness and response plan for all staff, residents, and volunteers had occurred.
Plan of Correction:	Director of Facility Ops or designee will conduct an Emergency preparedness and response in-service for all staff and residents by 2/29/24