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: Oct. 23, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2023 09:30 to 10:30 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 10/5/2023 regarding allegations in the areas of Admission, Retention, and Discharge of Residents An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. 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 #:	22VAC40-73-200-C
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure staff performing direct care staff duties met one of the requirements in this subsection. EVIDENCE: 1. Interview with staff person 1 on 10/23/2023 revealed that resident 1 was placed into a facility owned vehicle on 10/04/2023 along with staff persons 1, 2 and 3 and taken to his family member?s home. Interview with staff person 1 revealed that she and staff person 2 carried the resident, while he was in his wheelchair, up a flight of eight stairs into the home because the resident is not able to climb stairs. 2. Interview with staff person 1 on 10/30/2023 also revealed that staff person 2, date of hire 05/26/2022, does not have direct care staff training.
Plan of Correction:	1. Executive Director has educated staff member #2 regarding direct care requirements. 2. Executive Director or designee will ensure that a direct care staff member is present and providing hands on care for Residents who may need mobility assistance while Residents are being transported in a facility owned vehicle. 3. Executive Director or designee has educated team members who drive facility owned vehicles regarding requirement of direct care requirements.