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. 22, 2024 and March 25, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/22/2024 9:00AM until 1:15PM and 03/25/2024 9:30AM until 11:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/14/2024 regarding allegations in the area of: resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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. 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. Resident 1?s agreement with the facility was signed on 03/27/2023 and the resident?s physical move in date was 03/30/2023 per the facility?s ?move in form? provided by staff person 1. The record for resident 1 contains hospital documentation indicating that the resident was moving into the facility on 03/30/2023, had a fall and went to the ER due to her hitting her head on the sidewalk and obtained a small laceration to her scalp. 2. Hospital documentation indicates that the resident was sent to the hospital on 07/02/2023 for the following: fall, injury of head, left hip pain and multiple falls. Also, the hospital documentation states that the resident has had recurrent falls while on blood thinner in the setting of dizziness and hyperpolypharamacy indicating several potentially inappropriate medications in the elderly. 3. The aforementioned incidents were not reported to the regional licensing office.
Plan of Correction:	All clinical staff will be re-educated by ED on what is considered a major incident. RCC/MCD will immediately notify the ED of any major incident. ED will send formal report of major incident to regional licensing office within 24 hours.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 03/27/2023, indicates that the resident was assessed as assisted living level of care. 2. The record for resident 1 contains documentation from the emergency department, dated 07/02/2023, that the resident was brought to the emergency department due to a fall. 3. The record for resident 1 contains a healthcare practitioner fax communication form, dated 11/14/2023 and signed by a physician on 11/16/2023, that the resident had a fall on 11/14/2023 and that the resident said she hit her back on the metal piece of the bed frame and had been having dizzy spells on this date. 4. The record for the resident does not include an updated fall risk rating regarding the 07/02/2023 fall or the 11/14/2023 fall. Interview with staff person 1 confirmed that this is accurate.
Plan of Correction:	The RCC/MCD or designee will perform a complete audit of all Resident charts to ensure an initial fall risk assessment has been completed and is in resident chart. A Fall risk assessment will be completed annually, with change in condition, and after a fall. Fall risk assessments will be logged on audit tool
Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 03/27/2023, indicates that the resident was assessed as assisted living level of care. 2. The record for resident 1 contains emergency department documentation, dated 03/30/2023, that the resident presented to the emergency room due to a fall from standing position and an emergency department after visit summary, dated 06/15/2023, that the resident was in the emergency department due to a fall from standing. 3. The 03/30/2023 and 06/15/2023 fall risk assessments in the record for the resident do not contain documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls. 4. Interview with staff person 1 confirmed that this is accurate.
Plan of Correction:	RCC/MCD will discuss all falls during daily stand-up meeting. RCC/MCD will perform fall risk assessment and post fall investigation following all resident falls and log on fall audit tool. Copies of completed fall assessments and post fall investigation forms will be placed in resident file. RCC/MCD will update UAI/ISP due to falls and any new interventions.
Standard #:	22VAC40-73-470-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that, either directly or indirectly, the health care service needs of residents are met. EVIDENCE: 1. The record for resident 1 contains an emergency department after visit summary, dated 06/15/2023, and a neurosurgery after visit summary, dated 07/18/2023, that contained documentation for the following scheduled visits for the resident: arterial lower extremity duplex unilateral with vascular surgery visit on 08/16/2023 at 12:00PM and coordinated hearing test with audiology 08/22/2023 at 2:00PM. Interview with staff person 1 revealed that the resident did not attend the two aforementioned appointments. 2. The record for resident 1 contains documentation from an ophthalmology visit, dated 07/27/2023, that the resident was to return to the same ophthalmology office in two months for a follow-up visit. Interview with staff person 1 revealed that the resident did not attend this follow-up appointment. 3. The record for resident 1 contains an after-visit summary from the hospital, dated 09/03/2023 and 09/04/2023, that contained documentation for the following scheduled visit: arterial upper extremity duplex unilateral with vascular surgery on 10/17/2023. Interview with staff person 1 revealed that the resident did not attend this appointment. The same after-visit summary also contained documentation on page 1 that the resident was to follow-up with an ophthalmologist appointment (outpatient) and included instructions and contact information for the resident to call and schedule after 8:00AM on 09/05/2023. The resident had been in the hospital on 09/03/2023 through 09/04/2023 due to eye pain. Interview with staff person 1 revealed that this appointment was not scheduled and the resident never went to this appointment. 4. The record for resident 1 contains a physician?s progress note, dated 10/16/2023, that the resident?s presenting problem is right shoulder pain; therefore, the physician ordered an x-ray of the resident?s right shoulder along with an orthopedic evaluation/consultation for the resident requesting Tylenol 500MG by mouth twice daily. The record for the resident also contains a signed order for the aforementioned x-ray and orthopedic evaluation/consultation dated 10/16/2023. Interview with staff person 1 revealed that the resident did not have an x-ray or an orthopedic evaluation/consultation. 5. The record for resident 1 contains a physician?s progress note, dated 11/20/2023, that the resident has complaints of broken teeth with dental pain and to obtain a dental consult as soon as possible along with a signed physician?s order, dated 11/20/2023, for a dental consult as soon as possible. Interview with staff person 1 revealed that the resident did not have a dental consult. 6. Staff person 1 was also unable to provide any documentation on why the resident did not attend any of the aforementioned appointments.
Plan of Correction:	RCC/MCD or designee will review all post hospital paperwork when resident returns to community, fax to Pharmacy, print fax confirmation sheet, and initial and date. Follow Bin system instructions. An appointment calendar will be kept in RCC and MCD workspace. RCC/MCD or designee will schedule any ordered appointments and plot on calendar and make notation of appointment in resident record. The RCC/MCD or designee will print off copy of weekly appointments and give to ED or designee on Friday for the following week. ED or designee will schedule transportation if needed.
Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that all resident records shall be kept current. EVIDENCE: 1. Interview with staff person 1 revealed that the following physician progress notes, dated 03/31/2023, 04/04/2023, 04/24/2023, 05/01/2023, 05/03/2023, 06/12/2023, 06/15/2023, 06/22/2023, and 06/26/2023, had to be faxed to the facility on 03/07/2024 by the physician due to the aforementioned physician progress notes not being in the resident?s record or within the facility upon the licensing inspector?s request. 2. During resident 1?s record review, the LI noted that the resident?s record did not contain documentation of the resident?s 07/02/2023 emergency department visit. The LI requested and obtained the 07/02/2023 emergency department documentation since this document was not in the resident?s record. Interview with staff person 1 confirmed that the aforementioned emergency department visit documentation was not in the resident's record.
Plan of Correction:	ED will obtain a list of residents that are seen when house MD makes rounds. ED will have House MD fax progress notes within 24 hours to ED's attention. ED will compare progress notes to resident list, initial and date note and place in file folder in nursing office. Night shift clinical staff to file nightly. ED will use appointment calendar for all residents who follow up with outside MD and will call office to ensure office visit note is sent to community. ED will initial office note and file in file folder in Nursing office Clinical staff on night shift will file every night. If resident goes to ER, ED will ensure ER paperwork returns with resident or will call and request ER paperwork, initial and give to RCC/MCD to follow up any new medications/orders.
Standard #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on resident record review and staff interview, whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident?s return to the facility and the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. EVIDENCE: 1. Resident 1 was sent to the emergency department on 07/02/2023 due to having a fall. Hospital documentation indicates on page 20 the following information: de-prescribe medications that are causing/contributing to falls, dry mouth, constipation: stop oxybutynin due to high risk with little benefit, reduce metoprolol tartrate from 150MG two times a day to 100MG two times a day due to the resident being orthostatic on this date (systolic blood pressure drops from 130-103 with standing and heart rate ranges from 50-65 at rest), reduce trazodone from 100MG every night to 50MG every night, transition off of anticholinergic paroxetine to more appropriate SSRI in the elderly (reduce paxil 40MG to 30MG for two weeks, then reduce paxil 30MG to 20MG for two weeks, then reduce paxil 20MG to 10MG for two weeks then stop paxil; initiate Zoloft 25MG daily the day after the last dose of paxil 10MG), monitor weights 3x week, increase to furosemide 40MG two times a day for three days if greater than three pound weight gain in a day or greater than five pound weight gain in a week, follow-up incidental renal mass (right kidney with outpatient renal ultrasound), dry mouth (dental caries, gingivitis; was requested for a referral to dentistry), continue physical and occupational therapy as already doing at the facility and continue to use walker. The record for resident 1 does not contain documentation that the resident?s primary physician was made aware of all medication orders or that any contact was made with the resident?s primary physician regarding the new orders. Interview with staff person 1 confirmed that this was accurate. 2. Resident 1 was in the hospital from 09/03/2023 through 09/04/2023. The after-visit summary for this hospitalization indicated for the resident to start taking Dorzolamide eye drops and to ?ask how to take: acetaminophen 500MG (Tylenol)?. The record for resident 1 does not contain documentation that the resident?s primary physician was made aware of all medication orders or that any contact was made with the resident?s primary physician regarding the new orders. Interview with staff person 1 confirmed that this was accurate.
Plan of Correction:	When a resident has been hospitalized either prior to or upon return to community the RCC/MCD will fax primary MD and Pharmacy the hospital discharge paperwork noting any new orders or changed medications. RCC/MCD will attach fax confirmation sheet to discharge paperwork and initial and date and give to ED. ED will review, initial, and place in file folder in Nursing office to be filed. Nightshift RMA/Care Managers will file nightly. RCC/MCD will schedule all post hospital follow up and place on calendar and document in resident file.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 07/20/2023, for Advair (Fluticasone-Salmeterol 250-50) inhale one puff by mouth two times a day for COPD. 2. The August 2023 medication administration record (MAR) for the resident indicates that Fluticasone-Salmeterol 250-50 was being administered to the resident at 9:00AM and 5:00PM daily; however, the medication was not administered on the following dates/times: 08/12/2023 and 08/13/2023 at 9:00AM and on 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, and 08/14/2023 at 5:00PM due to ?medication ordered awaiting pharmacy delivery?; 08/10/2023 at 9:00AM due to ?medication ordered awaiting pharmacy delivery? and ?NP wrote new prescription today? and on 08/11/2023 at 9:00AM due to ?need a new script to fill ? contacting primary care physician?. 3. The record for resident 1 contains a signed physician?s order, dated 09/04/2023, for Dorzolamide 2% eye drops apply one drop in the morning, one drop at noon, and one drop before bedtime. 4. The October 2023 MAR for the resident indicates that Dorzolamide 2% eye drops were being administered to the resident at 8:00AM, 12:00PM and 8:00PM daily; however, the eye drops were not administered on 10/30/2023 at 12:00PM and 10/31/2023 at 8:00AM and 12:00PM due to ?pending delivery?. The November 2023 MAR for the resident indicates that Dorzolamide 2% eye drops are to be administered to the resident at 8:00AM, 12:00PM and 8:00PM daily; however, the eye drops were not administered on 11/01/2023 at 12:00PM (pending delivery), 11/02/2023 at 12:00PM (pending delivery), 11/03/2023 at 8:00AM (pending delivery) and 12:00PM (pending delivery), 11/04/2023 at 8:00AM (needs a new prescription), 12:00PM (needs new prescription) and 8:00PM (pending delivery) , 11/05/2023 at 8:00AM (needs new prescription. will call eye Doctor Monday) and 12:00PM (needs new prescription), 11/06/2023 at 8:00AM (waiting on new prescription), 12:00PM (waiting for new scrip), and 8:00PM (new script needed), 11/07/2023 12:00PM (waiting for new perscription [sic] to be faxed to pharmacy) and 8:00PM (notified MD that new script is needed) and 11/08/2023 at 8:00AM (other). The record for the resident contains a physician?s order, dated 11/06/2023 and signed by the physician on 11/09/2023, that the resident needs new script for Dorzolamide HCL 2% eye drops due to pharmacy request. The December 2023 MAR for the resident indicates that Dorzolamide 2% eye drops are to be administered to the resident at 8:00AM, 12:00PM and 8:00PM daily; however, the eye drops were not administered on 12/12/2023 at 8:00PM (pending delivery), 12/13/2023 at 8:00AM and 12:00PM (pending delivery), 12/14/2023 at 12:00PM (pending delivery) and 12/16/2023 8:00AM (pending delivery), 12:00PM (pending delivery ? pharmacy stated delivered Thursday, not on cart or in the refrigerator) and 8:00PM (pending delivery). 5. The record for resident 1 contains documentation that the resident was seen by the physician on 11/20/2023 due to request of facility staff for the resident having complaints of cough and congestion. The record for resident 1 contains a signed physician?s order, dated 11/20/2023, for Augmentin 875/127mg one tablet by mouth every 12 hours for 7 days for sinusitis. The November 2023 medication administration record (MAR) for resident 1 does not contain documentation that the aforementioned medication was ever administered to the resident. Interview with staff person 1 confirmed that this is accurate and that the physician?s order was never faxed to the pharmacy.
Plan of Correction:	(2) 4 hour Med Tech. refresher courses have been scheduled 4/25/2024 and 5/7/2024. All RMA's will take 4 hour Med. Tech refresher course or will be pulled off of the med. cart until they have proof of taking course. ED or designee will re-educate RCC, MCD, and all RMA's on The Bin System RCC/MCD or designee will check bin folders each morning and follow up on any orders that are in the file from the previous day.