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: May 7, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL

Comments:

Type of inspection: Monitoring Inspection was conducted via phone on 05/07/2024 to verify evidence for the violation of the standard cited in this notice. 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 #:	22VAC40-73-150-B-6
Description:	Based on collateral documentation and staff interview, the facility is currently being operated by an acting administrator for longer than 150 days. EVIDENCE: 1. The licensing inspector (LI) was notified via email by staff person 1 on 10/04/2023 that the facility?s current administrator?s last day would be 10/15/2023 and that the facility was naming staff person 2 as the facility?s acting administrator effective 10/16/2023. 2. Staff person 2 received their acting assisted living facility administrator-in-training license from Collateral 1 effective 12/05/2023 with an expiration date of 05/03/2024. 3. During phone call with staff person 1 on 05/07/2024, staff person 1 verified to the LI that they are still the facility?s acting administrator.
Plan of Correction:	TerraBella Pheasant Ridge will have an acting administrator in place by 5/17/2024.