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:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 12/07/2023, for Oxycodone-Acetaminophen 5MG-325MG tablet take one tablet by mouth every 8 hours for pain at 6:00AM, 2:00PM and 10:00PM daily. 2. The March 2024 medication administration record (MAR) for resident 1 indicates that the resident did not receive this medication at 2:00PM on 03/12/2024 and at 6:00AM on 03/13/2024 due to pending delivery of the medication to the facility. Also, the facility?s 24-hour shift report for 3PM-11PM on 03/12/2024 indicates that the resident?s narcotic was unavailable indicating that the resident also did not receive the aforementioned medication at 10:00PM on 03/12/2024. 3. Interview with staff person 1 during on-site inspection on 03/13/2024 confirmed that the resident?s medication was not available in the facility and that the resident was not administered the aforementioned three doses of scheduled Oxycodone-Acetaminophen 5MG-325MG.
Plan of Correction:	ED sending out letters to POA on 3/14/2024 if any resident is planned to leave the facility POA is to inform facility within 48 hours prior to LOA date to prepare pharmacy to deliver current medication to take with them. RMA or designee will ensure resident have medication on hand and following physician orders.