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: March 14, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/13/2024 7:55AM until 9:45AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/12/2024 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 self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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. 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 #:	22VAC40-73-680-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.