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: April 17, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 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: 04/17/2024 8:33AM until 11:00AM 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 04/05/2024 regarding allegations in the areas of: personnel and resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: personnel A violation notice was 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. 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 #:	22VAC40-73-130-A
Complaint related:	No
Description:	Based on documentation review, resident interview and staff interview, the facility failed to ensure that all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia report suspected abuse or neglect of residents in accordance with that section. EVIDENCE: 1. During an interview with the licensing inspector (LI) and resident 1 on 04/17/2024, it was revealed to the LI by resident 1 that staff person 4 had yelled at her concerning medication administration and that she had made staff persons 1 and 2 aware that staff person 4 had yelled at her concerning medication administration. 2. ocumentation provided to the LI by staff person 1 on 04/17/2024 contained documentation that was dated 04/09/2024, 04/10/2024 and 04/11/2024, that contained information that resident 1 had stated to staff persons 1 and 2 that staff person 4 had yelled at her. 3. Interview with staff person 2 on 04/17/2024 confirmed that the aforementioned information had not been reported to their local Adult Protective Services Agency (APS) as required by ?63.2-1606 of the Code of Virginia.
Plan of Correction:	APS notified us of the event on 4-17-2024. Staff #4 suspended pending APS investigation. Ed will conduct a staff meeting with all staff on mandating reporting.