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: June 26, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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: 06/26/2024 9:00AM until 2:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-325-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 07/18/2023, indicates that the resident was assessed as assisted living level of care. 2. The record for resident 1 contains a post fall investigation report that the resident had a fall on 05/22/2024; however, the report does not include interventions that were initiated to prevent or reduce the risk of subsequent falls. This was also noted by staff person 1.
Plan of Correction:	RCC/MCD or designee will discuss all falls during daily stand-up meeting. RCC/MCD or designee will perform fall risk assessment and post fall investigation following all resident falls and log on fall audit tool .Copy of fall report will be reviewed and initialed by ED or designee to ensure report includes interventions that were initiated to prevent or reduce the risk of subsequent falls. Copies of completed fall assessments and post fall investigation forms will be placed in resident file. RCC/MCD or designee will update UAI/ISP due to falls and any new interventions. ED or designee will check to ensure
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and staff interview, the facility failed to implement its medication management plan regarding methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. EVIDENCE: 1. The facility?s medication management plan states on page 4 and 5 the following: III. Proper procedures upon receiving an order from a physician (fax, verbal, or physical copy) verify medication order(s) are accurately transcribed to the MAR within 24 hours of receipt of new order or change in an order, verify the directions are appropriate and do not interfere with allergies noted in the resident chart and listed on QuickMAR, clarify with physician by fax or verbal order if necessary, fax order to pharmacy, and note new order in 24 hour report and in resident?s QuickMAR notes and section IV: proper procedure for shift supervisor: verify medication order(s) are accurately transcribed to the MAR within 24 hours of receipt of a new order or change in an order, all orders are to be approved in QuickMAR as they populate (with Flags) in the orders sections; ensure directions, diagnoses and times match physician orders, reconcile the order with the resident chart at time of approval and verify that there are no contradictory orders, allergies, or duplicate copies, ensure directions are clear and contain the medication, route, schedule, dosage and diagnosis and verify that there is a nursing note for each new order/change. 2. The record for resident 2 contains physician?s orders, dated 05/29/2024, for erythromycin apply 0.5 inches to left eye and left scalp two times daily for 7 days and acyclovir 800MG take one tablet by mouth five times daily for 7 days. The record for resident 2 also contains signed physician?s orders, dated 05/30/2024, for erythromycin 0.5% to left eye and blisters surrounding left eye three times daily for 10 days and for acyclovir 800MG take one tablet by mouth five times daily for 10 days. The record for the resident contains documentation that the 05/30/2024 physician?s orders were faxed to the pharmacy and the pharmacy acknowledged that it received the 05/30/2024 physician?s orders for resident 2. 3. The May 2024 and June 2024 MARs for resident 2 contains documentation that the resident received erythromycin ointment for 7 days two times a day from 5:00PM on 05/30/2024 until 9:00AM on 06/06/2024 and acyclovir 800MG tablets for 7 days from 12:00PM on 05/30/2024 until 8:00AM on 06/06/2024. 4. Interview with staff person 1 confirmed that the facility did not follow its medication management plan regarding the new orders or change in the orders for resident 2.
Plan of Correction:	All RMA?s will be re-educated on The Community Medication Management Plan by Area ED/ Nurse. RCC/MCD or designee will check new orders when they come in against current MAR to ensure medications have been transcribed correctly and initial the bottom of the order.