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 2, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 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: 05/02/2024 2:49PM until 4:45PM 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 05/02/2024 regarding allegations in the areas of: personnel, staffing and supervision & 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: resident care and related services 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 #:	22VAC40-73-280-B
Complaint related:	No
Description:	Based on document review and staff interview, the facility failed to implement its written staffing plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. EVIDENCE: 1. The facility?s written plan, provided by staff person 3, that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs, states that the facility will have 7 direct care staff from 7AM ? 3PM (first shift), 7 direct care staff from 3PM ? 11PM (second shift), and 5 direct care staff from 11PM ? 7AM (third shift). 2. Staff assignment sheets provided by staff person 3 contain documentation that on 04/06/2024 only 6 direct care staff were on duty from 7PM until 11PM; on 04/15/2024 only 6 direct care staff were on duty during first shift and only 6 direct care staff were on duty from 7PM ? 11PM or 8PM ? 11PM; and on 04/24/2024 only 6 direct care staff were on duty during first shift. 3. Staff person 3 confirmed that the aforementioned information is accurate.
Plan of Correction:	STANDARD NUMBER: 22VAC40-73-280B POC: Facility is utilizing OnShift scheduling program. RCC or designee will oversee the clinical staff schedule and utilize the OnShift scheduling program. The schedule will be staffed per Community Disclosure statement: 7am-3pm =7 direct care staff, 3pm-11pm=7 direct care staff, 11pm-7am =5 direct care staff. ED or designee and RCC?s will review staffing needs daily and make adjustments as necessary. RCC?s will cover call outs if unable to staff. Date to be corrected by: 6/7/2024
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observation and staff interviews, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. On 05/02/2024 at 10:13AM, it was brought to the attention of staff person 3 by the registered medication aide (RMA) on the medication cart for the third floor that there were prepoured medications in plastic cups for residents 1 through 7. 2. Staff person 3 contacted staff person 1 because staff person 1 was the RMA that had been assigned to the medication cart for residents 1 through 7 from 11PM-7AM. Staff person 1 revealed to staff person 3 that she had prepoured the 6:00AM medications for residents 1 through 7 and that she had not administered them to the residents before she left the facility at the end of her shift. During on-site inspection, the licensing inspector observed seven plastic medication cups for residents 1 through 7 that contained their 6:00AM scheduled medications. 3. The LI also spoke with staff person 1 and staff person 1 confirmed to the LI that she had prepoured the medications and that she did not administer the medications to residents 1 through 7 before she left at the end of her shift.
Plan of Correction:	STANDARD NUMBER 22VAC40-73-680B POC :All RMA?s will be re- educated on standard 22VAC40-73-680B by a licensed Health Care Provider. A complaint was submitted to The Board of Nursing re: Staff person #1 and employment was terminated. Date to be corrected by: 6/14/2024
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review and staff interviews, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instruction. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 02/21/2024, for levothyroxine 25MCG take one tablet daily for hypothyroidism. The May 2024 medication administration record (MAR) for the resident indicates that the medication is given to the resident daily at 6:00AM. The record for resident 2 contains a signed physician?s order, dated 10/12/2023, for levothyroxine 75MCG take one tablet daily for thyroid at 6:00AM. The record for resident 3 contains a signed physician?s order, dated 09/11/2023, for levothyroxine 75MCG take one tablet daily by mouth every morning for hypothyroidism at 6:00AM and divalproex SOD DR 125MG take one tablet by mouth every eight hours for mood at 6:00AM. The record for resident 4 contains a signed physician?s order, dated 09/18/2023, for levothyroxine 75MCG take one tablet by mouth every day for thyroid at 6:00AM. The record for resident 5 contains a signed physician?s order, dated 04/01/2024, for armour thyroid 300MG tablet take half tablet (equal to 150MG) every day for hypothyroidism at 6:00AM. The record for resident 6 contains a signed physician?s order, dated 04/17/2024, for levothyroxine 88 MCG take one tablet by mouth every day for hypothyroidism. The May 2024 MAR for the resident indicates that the medication is given to the resident daily at 6:00AM. The record for resident 7 contains a signed physician?s order, dated 06/29/2023, for levothyroxine 88 MCG take one tablet by mouth once daily on Monday, Tuesday, Wednesday, Thursday and Friday for thyroid at 6:00AM. The record for resident 8 contains a signed physician?s order, dated 03/21/2024, for xtampza er 9MG take one capsule by mouth twice daily for pain at 6:00AM and 5:00PM. 2. The May 2024 medication administration records (MARs) for residents 1 through 8 do not contain documentation that the aforementioned medications were administered to residents 1-8 on 05/01/2024. Interview with staff person 1 confirmed that they did not administer these medications to residents 1-8 per the physicians? orders. 3. The May 2024 MARs for residents 1 through 7 indicate that the aforementioned medications were administered to residents 1 -7 on 05/02/2024; however, interview with staff person 1 revealed that they documented on the MARs that the medications were administered but that they did not administer the medications to residents 1-7.
Plan of Correction:	STANDARD NUMBER 22VAC40-73-680D POC: The responsible party and the MD of residents 1-8 were made aware of medication errors by RCC. Date to be corrected: 5/2/2024