TerraBella Pheasant Ridge — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

128

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

TerraBella Pheasant Ridge was inspected 52 times between August 26, 2022 and May 26, 2026 by the Virginia Department of Social Services. 33 of those visits ended with violations cited and 19 with none. Across that history VDSS cited 128 violations under 64 distinct standards. 26 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

03/20/2027

Administrator

Jenifer Quilodran

Licensing inspector

Jennifer Stokes

Inspector phone

(540) 589-5216

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 26, 2026Inspection1 violation

Inspection dates

05/26/2026

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: 05/26/2026 9:10AM to 11:15AM 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 03/12/2026 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. 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

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current, retained at the facility, and kept in a locked area, except that information shall be made available as noted in subsection F of 22VAC40-73-560.

Evidence

Resident 1 was admitted to the facility on 02/12/2026. During the on-site inspection on 05/26/2026, the report of resident physical examination, dated 01/29/2026, in the record for resident 1 contained documentation on page 2 that the resident had a pressure ulcer of sacral region, stage 3 healing. The report of resident physical examination contained an order summary report by Collateral 1 that stated on page 1 of 7 that the resident had a pressure ulcer of sacral region, stage 2 and a pressure ulcer of sacral region, stage 3 listed under the resident’s diagnoses. The order summary report also included on page 5 of 7 wound care orders one time a day on Monday, Wednesday, and Friday for a wound and a pressure injury over the resident’s left buttock. During an interview with the licensing inspector (LI) and staff persons 1 and 2, staff persons 1 and 2 informed the LI that resident 1 had not been receiving wound care for the wound(s) because the wound(s) had healed; however, during the on-site inspection the record for resident 1 did not contain information that the wound(s) had healed and that wound care was to be discontinued. On 06/05/2026, staff person 1 emailed the LI a progress note from Collateral 2, dated 05/26/2026 at 2:11PM, that the resident’s stage 2 sacral ulceration had healed at the time Collateral 2 had evaluated the resident on 02/17/2026. Staff person 1 confirmed that this information was not available in the resident’s record or at the facility during the on-site inspection on 05/26/2026.
During the on-site inspection on 05/26/2026, the record for resident 1 contained a signed physician’s order, dated 02/17/2026, for compression stockings, daily at 8AM and off at 6PM. The LI asked staff persons 1, 2 and 3 for documentation of where the resident’s compression stockings were being put on and taken off daily by staff; however, no documentation of this was provided during the on-site inspection. On 06/05/2026, staff person 1 emailed the LI a progress note from Collateral 2, dated 05/26/2026 at 2:11PM, that the order for compression stockings that was written by Collateral 2 was for the resident to self-apply herself – encouraged to request for help if unable to get them on herself. Staff person 1 confirmed that this information was not available in the resident’s record or at the facility during the on-site inspection on 05/26/2026.

Plan of correction

If a resident is admitted with wound care orders and assessment findings indicate the wound has healed, the NP will document the healed status in the assessment and document orders to discontinue wound care treatment. If compression stockings are ordered and the resident is independent with application and removal, the NP will document the resident's level of independence in the initial assessment. The ED/DHW will review all admission orders and supporting documentation upon admission and compare them to the NP initial assessment to ensure all active diagnoses, treatments, wound care orders, and physician orders are accurately reflected, clarified, or discontinued as appropriate. Any discrepancies will be addressed with the NP and/or physician and resolved during the admission process. The ED/DHW will audit all new admissions for 30 days to ensure physician orders, assessments, and resident records are reconciled and accurately documented.

May 26, 2026Inspection0 violations

Inspection dates

05/26/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 12, 2026Inspection7 violations

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/12/2026 7:35AM to 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: breakfast, morning medication administration, medication cart audit, activities 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. 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

22VAC40-73-450-F

Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for significant change of a resident’s condition.

Evidence

The ISP for resident 5, dated 10/07/2025, contains documentation that the resident is prescribed Furosemide 20MG – take 1 tablet by mouth every day for heart failure and hold if blood pressure is less than 100/50 and Metoprolol Tartrate 50MG – take 1 tablet by mouth 2 times a day for AFIB and hold if blood pressure is less than 100/50 or heart rate is less than 60 beats per minute; however, the parameters on these two medications were discontinued by the physician on 01/30/2026. Interview with staff person 2 confirmed that the resident’s ISP has not been updated to reflect this change.
The record for resident 5 contains three fall risk assessments dated 01/04/2026, 01/13/2026 and 01/18/2026 that contain documentation that the resident is a high fall risk; however, the resident’s ISP, dated 10/07/2025, indicates the resident is a low fall risk. Interview with staff person 2 confirmed that the resident’s ISP has not been updated to reflect this change.

Plan of correction

When a new order or change order is written and is being approved, a copy of the order will be given to the ED with the updated ISP for ED to sign off The ISP.

22VAC40-73-450-E

Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative.

Evidence

The ISP in the record for resident 3 was updated on 11/11/2025 to reflect that the resident’s legal representative had signed a DNR for resident 3; however, the ISP has not been signed by the licensee, administrator, or a designee or by the resident or his legal representative.
Interview with staff person 2 confirmed this is accurate.

Plan of correction

DHW,RCC, and MCD will perform an audit of all lSP's to ensure they all contain ED and RP signatures.

22VAC40-73-440-D

Based on resident record review and staff interview, the facility failed to ensure for private pay individuals the uniform assessment instrument (UAI) shall be completed as required by 22VAC30-110.

Evidence

The UAI for resident 3, dated 03/18/2025, does not contain documentation for medication administration on page 2 of 2. Also, there is documentation that resident 3 is wandering/passive – less than weekly; however, there is no documentation of the type of inappropriate behavior and documentation that the resident is disoriented – some spheres, some of the time; however, there is no documentation of which spheres are affected.
Interview with staff person 2 confirmed this is accurate.

Plan of correction

ED and staff member who completes the UAI assessment will review UAI together and any needed correction will be completed before ED will sign off on UAI.

22VAC40-73-870-A

Based on observation, the facility failed to ensure that the interior of all buildings should be maintained in good repair and kept clean and free of rubbish.

Evidence

During the on-site inspection, on 02/12/2026, while performing the physical plant inspection of the assisted living, a Licensing Inspector observed a large brown stain on the carpet outside of the door to room 237 at 08:42 AM.
An interview with staff persons 1 and staff 2 on the same date revealed that staff were unaware of the stain.

Plan of correction

Carpet was shampooed day of inspection.

22VAC40-73-640-A

Based on facility medication management plan and medication cart audit, the facility failed to ensure to implement its medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.

Evidence

The facility’s medication management plan states on page 367 that shift counts are performed at the end of each shift, or when the RMA responsible for medication changes, a complete count will take place by the RMA going-off and the RMA coming on, the RMA on shift pulls the Controlled Substance Shift Count form and reports to the on-coming RMA the quantity of medication that should be in each package, the oncoming RMA counts the medication in container and verifies the count and if the quantity is verified both the on-coming and off-going RMAs will sign the Controlled Substance Count Form.
During the on-site inspection at approximately 8:03AM, the licensing inspector (LI) and staff persons 2 and 3 observed that there were multiple dates/times on the February 2026 Narcotic Count Key Transfer Sheet that did not contain the signature of either the outgoing or the oncoming medication administration staff person.

Plan of correction

DHW,RCC, and MCD have all been assigned a medication cart. Every morning they will audit the narcotic count sheet to ensure narcotics have been counted and sign off on a narcotic count check sheet and give to ED.

22VAC40-73-1090-A

Based on resident record review and staff interview, the facility failed to ensure prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

Resident 3 was admitted to the facility’s safe, secure environment on 03/21/2025; however, the assessment of serious cognitive impairment document was not completed by a physician until 03/24/2025.
Interview with staff person 2 confirmed this is accurate.

Plan of correction

Admission check sheet will be utilized for all new admissions. Resident will not be allowed to move in if all paperwork is not received prior to resident arrival.

22VAC40-73-680-E

Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented and the documentation should be maintained in the resident’s record.

Evidence

During the on-site inspection, the record for resident 4 contained a physician’s order sheet, signed 01/13/2026, which contained orders for OXYCODONE 20 MG TABLET – Take one tablet by mouth 2 times a day for pain. Hold if BP < 100/60, effective 12/29/2025.
A review of the January 2026 medication administration record (MAR) for resident 4 contained the same order; however, neither the MAR nor the record for resident 4 contained documentation of twice daily blood pressure readings.
An interview with staff 2 during the on-site inspection revealed that blood pressure reading documentation did not exist.

Plan of correction

DHW called pharmacy to ensure that when pharmacy receives an electronic order from MD/NP the pharmacy will send a copy of the order to the community.

January 20, 2026Complaint survey4 violations

Inspection dates

01/20/2026, 02/12/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/20/2026 8:30AM to 3:00PM & 02/12/2026 7:35AM to 2:30PM 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 11/19/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 75 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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

22VAC40-73-680-I

Based on resident medication administration record (MAR) review, the facility failed to ensure that all required information was documented on resident MARs.

Evidence

The October 2025 MAR for resident 1 does not have documentation of staff initials for the administration of the following prescribed medications: Metoprolol Tartrate 100mg 8:00 am on 10/27/2025; 10/28/2025; 10/29/2025; 10/30/2025; and 10/31/2025; Furosemide 20 mg 8:00 am on 10/27/2025; 10/28/2025; 10/29/2025; 10/30/2025; and 10/31/2025; Digoxin 125mg at 8:00 am on 10/27/2025; 10/28/2025; 10/29/2025; 10/30/2025; and 10/31/2025. Staff person 2 confirmed this is accurate.

Plan of correction

DHW,MCD,RCC will audit Mar's each shift to ensure all medications are being administered as ordered and documentation is completed.

22VAC40-73-470-A

Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of resident are met.

Evidence

The record for resident 1 contains a signed physician’s order, dated 09/29/2025, for wound care/treatment to the resident 1’s right edema, cellulitis/abscess Monday, Wednesday and Friday. 2.The record for resident 1 contains documentation that the resident only received the aforementioned wound care/treatment two times during the week of 09/28/2025 - 10/04/2025 on 09/29/2025 and 10/03/2025; and two times during the week of 10/19/2025 - 10/25/2025 on 10/21/2025 and 10/24/2025. Staff persons 1 and 2 confirmed this is accurate.

Plan of correction

DHW, RCC, and MCD held a meeting with all Home Health and Hospice providers who service the community. Guidelines for required documentation explained: Must leave a narrative note of service provided and any change in orders and/or visit frequency in Resident's Community Hospice/ Home Health notebook prior to leaving community after visit. Hospice/Home Health office to send completed computer documentation within 1 week.

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure that all resident records shall be kept current and retained at the facility.

Evidence

The record for resident 1 contains a signed physician’s order, dated 09/29/2025, for skilled nursing to perform dressing change to right edema, cellulitis/abscess Monday, Wednesday, and Friday.
During on-site inspection on 01/20/2026, the record for resident 1 only contained wound care notes for the following dates: 10/06/2025; 10/10/2025; 10/14/2025; 10/24/2025/10/27/2025; 10/30/2025; 10/31/2025; 11/10/2025; 11/11/2025 and 11/14/2025. On 01/29/2026, one licensing inspector (LI) emailed staff persons 1 and 2 requesting additional wound care hospice notes for resident 1. On 01/30/2026, staff person 2 emailed the LI additional wound care notes that were obtained from the hospice agency for resident 1 as they were not available at the facility during the on-site inspection.

Plan of correction

22VAC40-73-450-F

Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident’s condition.

Evidence

The record for resident 1 contains a signed physician’s order, dated 09/29/2025, for skilled nursing to perform dressing change to right edema, cellulitis/abscess Monday, Wednesday, and Friday.
The signed ISP in the record for resident 1, dated 8/18/2025, does not include wound care as an identified need. Interview with staff persons 1 and 2 revealed that the resident was receiving wound care from hospice three times per week and that resident 1’s ISP had not been updated to include this identified need. Staff person 2 confirmed this is accurate.

Plan of correction

DHW, MCD, RCC to perform complete audit of all lSP's for residents utilizing Hime Health or Hospice Services to ensure that all needs are included on the ISP.

January 20, 2026Inspection1 violation

Inspection dates

01/20/2026

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: 01/20/2026 – 08:30AM – 03:00PM 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 12/15/2025 regarding allegations in the area(s) of: Resident Care and Related Services . Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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. An exit meeting will be conducted to review the inspection findings. 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 or by email at Jennifer.stokes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on resident record review and staff interview, the facility failed to ensure that a report was made to the regional licensing office within 24 hours of a major incident that negatively affected the health of a resident.

Evidence

A review of facility records on date of on-site inspection on 01/20/2026, included documentation of a fall for resident 1 on 12/08/2025 that resulted in the need for emergency medical care for an injury to the face and head. As of the date of on-site inspection no report of the incident had been made to the regional office concerning an incident with injury on 12/08/2025.
In an interview conducted on the date of on-site inspection with two Licensing Inspectors (LIs) and staff person 1, staff person 1 confirmed the incident was not reported to regional office within 24 hours.

Plan of correction

DHW, RCC, and MCD re-educated on procedure to be followed for state reportable incidents. All state reportable incidents and formal report follow up will be completed and sent to licensing by the ED only.

January 20, 2026Inspection2 violations

Inspection dates

01/20/2026

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: 01/20/2026 8:30AM to 3:00PM 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 11/17/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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

22VAC40-73-70-A

Based on resident record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

The record for resident 1 contains a note by staff person 3 at 6:15PM on 08/30/2025 that resident 1 was observed sitting in living room floor in an upright position scooting across floor on buttocks, resident was requesting help up due to falling on floor when trying to fix her TV and skin tear was observed to left elbow. The licensing inspector (LI) was provided an incident report for resident 1, dated 09/11/2025 at 4:35AM, that the resident was found in her bathroom on the floor with a small cut and knot on the back of her head, resident stated she fell going to the bathroom and was not sure how it happened. The LI was provided an incident report for resident 1, dated 11/24/2025 at 6:35AM, that resident 1 was calling for help when staff got onto the second floor, staff helped the resident up out of her bed and noticed dried blood on the back of her gown. Resident 1 stated that she hit her head. Resident 1 was observed with a cut on the back of her head.
As of on-site inspection on 01/20/2026, the LI had not received a report from the facility for the three aforementioned incidents involving resident 1. Interview with staff person 1 confirmed this is accurate.

Plan of correction

22VAC40-73-70-C

Based on resident record review and staff interview, the facility failed to ensure to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident and the report shall be signed and dated by the administrator and include all required components.

Evidence

The licensing inspector (LI) received an email from staff person 1 at 2:53PM on 08/26/2025 that resident 1 fell on the morning of 08/26/2025.
The record for resident 1 contains a note by staff person 4, dated 08/26/2025 at 2:15PM, that resident 1 was found on the floor today in her room at the foot of her bed with head up by the bathroom door, resident stated that she slid out of her bed, and resident had hit her head and cut it. The record for resident 1 contains a note by staff person 3, dated 08/26/2025 at 1:30PM, that hospice notified staff person 3 that hospice had checked in with the resident at the emergency room.
As of on-site inspection on 01/20/2026, the LI had not received additional information regarding this incident involving resident 1 on 08/26/2025. Interview with staff person 1 confirmed this is accurate.

Plan of correction

January 20, 2026Inspection2 violations

Inspection dates

01/20/2026

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: 01/20/2026 – 08:30 am – 03:00 pm 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 11/14/2025 regarding allegations in the area(s) of: Resident Care and Related Services . Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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. An exit meeting will be conducted to review the inspection findings. 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 or by email at Jennifer.stokes@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on resident record review and staff interview, the facility failed to ensure that medications were administered according to physician’s instructions.

Evidence

The record for resident 1 has a physician’s order, signed on 10/29/2025, for Quetiapine 25MG TID at 8:00AM, 12:00PM and 8:00PM. As of the date of on-site inspection on 01/20/2026, the signed Medication Administration Record (MAR) for November 2025, has administration times of 8:00AM, 2:00PM and 8:00PM for Quetiapine 25MG. Interview with staff person 1 confirmed this is accurate.

Plan of correction

DHW, RCC, and MCD re-educated by ED on procedure for accepting/clearing medication orders after being inputted in ECP system by Pharmacy. If orders are not input into system by Pharmacy exactly as written by MD; order is not to be accepted. DHW,RCC, or MCD must call Pharmacy and clarify the order with the Pharmacy and ensure the orders is input exactly as written by MD before accepting the order.

22VAC40-73-680-I

Based on a resident record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the name, signature, and initials of all staff administering medications.

Evidence

During on-site inspection on 01/20/2026, the record for resident 1 has a physician’s order, signed on 10/29/2025, for Quetiapine 25mg TID at 8:00AM, 12:00PM and 8:00PM. The signed Medication Administration Record (MAR) for November 2025, has no staff initials for the 12:00PM dosage on 11/01/2026, 11/02/2026, 11/03/2026, 11/04/2026 and 11/05/2026.
In an interview with staff person 1 and two licensing inspectors (LIs), staff person 1 acknowledged that the medication was given; however, the November 2025 MAR was not updated to include staff initials at the time of administration.

Plan of correction

DHW and/or designee will re-educate all RMA staff on proper documentation for medication administration. DHW or designee will observe 1 medication pass and documentation with each RMA.

January 20, 2026Complaint survey0 violations

Inspection dates

01/20/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 01/20/2026 8:30AM to 3:00PM 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 11/05/2025 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 8, 2025Complaint survey0 violations

Inspection dates

10/08/2025

Areas reviewed

22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 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: 10/08/2025 8:40AM to 8:45AM 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 09/29/2025 regarding allegations in the area of: buildings and grounds 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 26, 2025Complaint survey0 violations

Inspection dates

09/26/2025

Areas reviewed

22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 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: 09/26/2025 9:25AM to 9:35AM 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 09/23/2025 regarding allegations in the area of: buildings and grounds Observations by licensing inspector: memory care unit 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 13, 2025Inspection1 violation

Inspection dates

08/13/2025

Areas reviewed

22VAC40-73 PERSONNEL

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: 08/13/2025 10:00AM to 2:31PM 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 08/06/2025 regarding allegations in the areas of: personnel Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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

22VAC40-73-110-1

Based on facility self-reported incident and facility documentation, the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.

Evidence

The licensing inspector (LI) received a self-reported incident via email from staff person 1 on 08/06/2025 with the following information: on 07/30/2025, staff person 4 was informed by staff person 2 that on 07/29/2025 staff person 3 told staff person 2 to send a picture of resident 1 to resident 1’s wife. In the screenshot there was a picture of the resident standing in front of his wheelchair with his shirt pulled up some and his pants pulled down his legs, the resident was wearing an adult brief at the time of the picture, and you can see the body of someone standing there talking to the resident. Staff person 2 was upfront that staff person 3 took the picture and sent it to her stating “show this to his wife so she can see his behaviors”. The message under the picture sent by staff person 2 stated “look at the show your husband was putting on”; resident’s wife responded upset stating that it should have been stopped, it wasn’t funny, and if it continues, she will pull him out of the facility.
Additional documentation provided by the facility during on-site inspection on 08/13/2025 to the LI confirmed that staff person 3 was the staff person who took the picture and staff person 2 was the staff person who texted the picture. Both staff persons 2 and 3 were suspended on 07/30/2025. Staff person 2 was terminated from employment with the facility on 08/05/2025 and staff person 3 was terminated from employment with the facility on 08/04/2025 due to both staff persons being in violation of resident rights as stated on the counseling documentation forms for both staff persons.

Plan of correction

Plan of Correction: All staff will be re-educated on Resident Rights. Terra Bella Pheasant Ridge Administrator will continue to self-report any allegations of Resident Rights violations.

August 13, 2025Complaint survey6 violations

Inspection dates

08/13/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 08/13/2025 10:00AM to 2:31PM 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 07/24/2025 regarding allegations in the areas of: resident care and related services, resident accommodations and related provisions, & buildings and grounds Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: resident room and safe, secure unit An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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

22VAC40-73-870-B

Based on observation during a tour of the resident’s bedroom and staff interview, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors.

Evidence

At approximately 10:05AM during on-site inspection on 08/13/2025, the licensing inspector (LI) and staff person 2 noted a strong stale and musty odor in resident 1’s bedroom and resident 1’s adjoining bathroom.

Plan of correction

Plan of Correction: DHW/MCD will walk resident rooms each morning and notify housekeeping of any rooms that have odor so that housekeeping can clean room. Date to be Corrected by: 9/8/2025

22VAC40-73-740-D

Based on staff interviews, the facility failed to ensure to develop and implement a written policy regarding procedures to be followed when a resident’s clothing or other personal possessions, such as jewelry, television, radio, or other durable property, are reported missing, attempts shall be made to determine the reason for the loss and any reasonable actions shall be taken to recover the item and to prevent or discourage future losses, and the results of the investigation shall be reported in writing to the resident and documentation shall be maintained for at least two years regarding items that were reported missing and resulting actions that were taken.

Evidence

Interview with staff person 1 during on-site inspection on 08/13/2025 revealed to the licensing inspector (LI) that it had been reported to her that resident 1’s blue sherpa blanket was missing; however, staff person 1 informed the LI that she did not follow-up with the individual who reported the missing blanket and there is no documentation regarding her investigation.
Interview with staff persons 1 and 2 revealed that the facility does not have a written policy regarding what the facility is to do when items are reported missing.

Plan of correction

Plan of Correction:ED will write policy regarding procedures to be followed when a residents clothing or personal items go missing. Date to be Corrected by: 9/8/2025

22VAC40-73-870-E

Based on observation during a tour of the resident’s bedroom and staff interview, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture and showers, shall be kept clean and in good repair and condition, except that furnishings owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.

Evidence

At approximately 10:08AM during on-site inspection on 08/13/2025, the licensing inspector (LI) and staff person 2 noted that the blue oversized chair in resident 1’s bedroom contained a small area of a brown substance on the middle of the chair’s cushion. Staff person 2 informed the LI that the chair belongs to the resident.
At approximately 10:09AM, the LI and staff person 2 noted that the shower drain cover in the resident’s walk-in shower was missing and that the drain contained a dark, colored substance around the top of the drain and inside of the drain.

Plan of correction

Plan of Correction: Drain cover was replaced the same day. DHW/MCD will walk resident rooms each morning and notify housekeeping/clinical staff of any rooms that need cleaning. DHW/MCD will check residents room again at end of day to ensure the cleaning was completed. MCD/DHW will document in resident record that cleaning was completed. Date to be Corrected by: 9/8/2025

22VAC40-73-640-A

Based on resident record review and facility plan review, the facility failed to ensure to implement its medication management plan in regard to methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.

Evidence

The facility’s medication management plan provided to the licensing inspector (LI) during on-site inspection on 08/13/2025 states the following information on page 344: MP18- Medication Refills – medication refills will be obtained in a timely manner to ensure residents have all physician or other healthcare practitioner ordered medication available. 1. The registered medication aide (RMA) on-duty contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to a medication running out unless the medication is on a cycle refill with the pharmacy. a. The Community will be compliant with all pharmacy documentation and requests related to cycle refills of medications. b. The medication is entered on the Medication Refill – New Order Roster. c. Notify the family or responsible party, when necessary, for medication pickup. 2. If necessary, contact the prescribing physician/practitioner for a new order. 3. Medication staff work to ensure medications are not allowed to run out unless directed by the prescribing physician/practitioner. a. Medication staff will coordinate refills with the pharmacy and resident’s responsible party. i. if the responsible party is required to obtain medication refills, such as when using an outside pharmacy, they will be given sufficient notice when a medication refill is required. 1. If the responsible party fails to obtain the medication refill(s), medication staff will document this as a missed medication and appropriate procedures will be followed. 4. RMAs on each shift are responsible for making the necessary reminder and follow-up calls/faxes to assist with the receipt of medications. 5. The Director of Health and Wellness will be notified immediately when any delay in the receipt of medication results in the unavailability of the medication to be given to a resident. 6. Medication refills are logged on the Centrally Stored Medication Log. a. A log or bound book provided by the pharmacy, or a pharmacy record of medication delivery may be used in lieu of the Centrally Stored Medication Log. i. The pharmacy log, book, or record of medication delivery must include the same information contained on the Centrally Stored medication Log and account for every medication in central storage.
The July 2025 medication administration record (MAR) for resident 1 contains documentation that the resident was to be administered Lorazepam 0.5MG take half tablet = 0.25MG by mouth daily for 7 days at 9:00AM from 07/03/2025 to 07/09/2025; however, the resident was not administered the aforementioned medication at 9:00AM on 07/06/2025, 07/07/2025, 07/08/2025, and 07/09/2025 due to “pending delivery”.
In a follow-up email with staff person 2 on 08/19/2025, staff person 2 confirmed that the facility did not implement its medication management plan in regard to medication refills to ensure resident 1 did not have any missed dosages of their medication.

Plan of correction

Plan of Correction: DHW/MCD will review Medication Management Plan with all RMA's. DHW/MCD will observe each RMA perform Medication pass. Date to be Corrected by: 9/8/2025

22VAC40-73-680-I

Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) included the date, time given, and initials of direct care staff administering medications.

Evidence

Resident 1’s August 2025 MAR contains documentation that the resident is prescribed Divalproex SOD DR 250MG, Memantine HCL 10MG, and Buspirone HCL 10MG daily at 5:00PM.
The resident’s August 2025 MAR does not contain the initials of which staff person administered the aforementioned medications to the resident at 5:00PM on 08/09/2025. Interview with staff person 2 revealed to the licensing inspector (LI) that the medications were given; however, the staff person didn’t document on the August 2025 MAR that the medications had been administered.

Plan of correction

Plan of Correction: DHW/MCD will review Medication Management Plan with all RMA's. DHW/MCD will observe each RMA perform Medication pass. Date to be Corrected by: 9/8/2025

22VAC40-73-460-H

Based on resident record review and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met including assistance or care with bathing at least twice a week, but more often if needed or desired.

Evidence

The uniform assessment instrument (UAI) for resident 1, dated 10/31/2024, indicates the resident requires mechanical help and human physical assistance with bathing. The individualized service plan (ISP) for resident 1, dated 12/06/2024, indicates the resident requires mechanical and human physical assistance with bathing – care staff are to provide physical assistance to transfer the resident in and out of the shower and to wash the resident’s upper and lower body while the resident uses a shower chair and available grab bars. Staff person 1 confirmed the resident needs the aforementioned assistance with bathing.
Interview with staff person 1 revealed that the facility utilizes the document “Shower/laundry/linen & skin observation sheet” as documentation of when a resident receives a shower. Staff person 1 stated to the licensing inspector (LI) that the resident’s scheduled shower days are Wednesdays and Saturdays.
The record for resident 1 contains the following documentation that the resident only received a shower during June 2025 to 08/13/2025 on the following dates (the date of on-site inspection): 06/04/2025, 06/11/2025, 06/14/2025, 06/18/2025, 06/25/2025, 06/28/2025, 07/02/2025, 07/09/2025, 07/16/2025, 07/23/2025, 07/30/2025, and 08/06/2025. Interview with staff person 1 during the on-site inspection revealed that she could not locate any additional documentation of the resident receiving any additional showers.

Plan of correction

Plan of Correction: DON/MCD will review and initial shower sheets daily. Any resident who refuses a shower/bath will be rescheduled to the next day and the refusal and rescheduled shower/bathe will be documented in the resident record Date to be Corrected by: 9/8/2025

August 13, 2025Complaint survey0 violations

Inspection dates

08/13/2025

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: 08/13/2025 11:30AM to 1:20PM 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 08/13/2025 regarding allegations in the area(s) of: additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 74 Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 13, 2025Complaint survey0 violations

Inspection dates

08/13/2025

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: 08/13/2025 10:00AM to 1:20PM 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 08/12/2025 regarding allegations in the area(s) of: additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 74 Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: memory care 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 30, 2025Complaint survey4 violations

Inspection dates

06/30/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 06/30/2025 9:53AM to 1:45PM 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 06/24/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 64 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 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

22VAC40-73-40-A

Based on resident record review, facility documentation, and staff interview, the licensee failed to ensure compliance with the facility’s own policies and procedures.

Evidence

During on-site inspection on 06/30/2025, staff person 2 provided the licensing inspector (LI) an alert charting log document that contains information that staff are to document on each shift, until the director of health and wellness indicates that the resident should no longer be included in the alert charting. An example of a resident that would need to be included on the alert charting log is when a resident begins antibiotic therapy – document vital signs and any adverse reactions for the duration of the treatment.
Staff person 2 informed the LI that resident 1 was added to this document on 06/13/2025 because resident 1 was prescribed Doxycycline 100MG by mouth every 12 hours for 10 days. The resident’s June 2025 medication administration record (MAR) contains documentation that the resident was administered Doxycycline 100MG from 06/13/2025 to 06/20/2025 at 8:00AM and 8:00PM daily and on 06/21/2025 at 8:00AM. Staff person 2 informed the LI that the resident’s temperature should have been taken every shift while the resident was taking Doxycycline 100MG as indicated in the instructions of the facility’s alert charting log.
During the on-site inspection on 06/30/2025, staff person 2 revealed that she was unable to provide documentation to the LI that the resident’s temperature had been taken every shift per the instructions of the facility’s alert charting log.

Plan of correction

All RMA’s will be re-educated on what all needs to be documented on alert charting. DHW/RCC will monitor the alert charting book every morning to ensure RMAs are properly documenting. If there are omissions the staff will be asked to come back to the facility to complete documentation

22VAC40-73-450-H

Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.

Evidence

The ISP in the record for resident 1 contains an update on 06/19/2025 for care staff to conduct round checks every 2 hours on the resident for safety and toileting.
During on-site inspection on 06/30/2025, the licensing inspector (LI) was provided with a 2-hour rounding log for resident 1 which was implemented on 06/19/2025; however, the log did not contain staff initials of staff having rounded on the resident on 06/20/2025 at 8:00PM and 10:00PM and on 06/21/2025 at 12:00AM and 2:00AM. Interview with staff persons 1 and 2 confirmed this is accurate.

Plan of correction

DWH/RCC/ designee will review rounding sheets each morning to ensure log is complete. If incomplete the staff who work will be called into work to complete log.

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility.

Evidence

The individualized service plan (ISP) in the record for resident 1 contained documentation that the resident had received skilled nursing, physical therapy and occupation therapy services from a home health agency; however, the three services had been marked through with a red marker indicating that the services had been discontinued.
The licensing inspector (LI) asked to see the home health documentation/notes regarding the services they provided to the resident; however, staff person 2 informed the LI that she was unable to locate the documentation/notes in the facility and had to reach out to the home health agency to obtain the notes for the LI’s review.

Plan of correction

DHW/RCC will speak with each HH/Hospice Company Representative and let them know we require a notebook and want notes sent over at least weekly. DHW/RCC will monitor notebooks weekly to ensure all notes are up to date. If they are not will reach out to Company and request they are sent over immediately.

22VAC40-73-470-A

Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.

Evidence

The record for resident 1 contains a signed physician’s order, dated 05/15/2025, for the facility to schedule an ortho consult for proximal subluxation of first metacarpal.
During on-site inspection on 06/30/2025, the licensing inspector (LI) was informed by staff person 2 that the resident requires assistance with making/arranging medical appointments and that the facility makes medical appointments for the resident. Interview with staff person 2 revealed to the LI that they were unable to provide documentation that an appointment had been made for the resident or that the resident had been to an ortho consult appointment.

Plan of correction

DHW/RCC will keep a community calendar and when residents have a follow up appointment will put it on the calendar and give a note to the front desk to schedule. Every morning the DHW/RCC will review the calendar and compare it with front desk list to ensure all appointments are being scheduled.

June 30, 2025Complaint survey0 violations

Inspection dates

06/30/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 2, 2025Inspection1 violation

Inspection dates

06/02/2025

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: 06/02/2025 9:30AM to 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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

22VAC40-73-660-B

Based on observation, resident record review, resident interview, and staff interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.

Evidence

The UAI in the record for resident 1, dated 03/07/2025, indicates that the resident requires their medications to be administered/monitored by lay person.
At approximately 10:03AM during on-site inspection on 06/02/2025, the licensing inspector (LI) noted the following in the resident’s room: Prevagen, Gold Bond extra strength body powder, Thera Tears eye drops, and a spray bottle of Medline MicroKlenz first aid antiseptic. Interview with resident 1 revealed that he takes Prevagen once a week, has used the Gold Bond extra strength body powder, does use Thera Tears eye drops and that the Medline MicroKlenz first aid antiseptic has been used by home health for his right leg/foot. These medications were also observed by staff persons 1 and 2.
The record for resident 1 did not contain physician’s orders for the resident to have and self-administer the aforementioned medications. Interviews with staff persons 1, 2 and 3 confirmed this is accurate.

Plan of correction

DHW/RCC/MCD will perform an audit of all Resident charts and compare UAI and Orders to self administer medications to ensure UAI/ISP and orders match.

June 2, 2025Complaint survey1 violation

Inspection dates

06/02/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 06/02/2025 9:30AM to 2:30PM 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 03/28/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 71 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 8 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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

22VAC40-73-450-F

Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for significant change of a resident’s condition.

Evidence

The ISP in the record for resident 1, dated 02/21/2024, contained documentation of an identified need, provisions for signaling every two hours, and that the resident required rounds to be performed every two hours to ensure safety and well-being of the resident.
When the licensing inspector (LI) asked for documentation of the rounds that were provided for resident 1, staff person 1 informed the LI that the resident did not require rounding and that the resident’s ISP had not been updated to reflect that this was not an identified need of the resident.

Plan of correction

DHW/RCC/MCD will perform an audit of all ISP’s to ensure they have been updated at least every 12 months and with significant change. ED will retrain RCC/DHW/MCD on ISP’s.

June 2, 2025Complaint survey2 violations

Inspection dates

06/02/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 06/02/2025 9:30AM to 2:30PM 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 04/28/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 71 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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

22VAC40-73-470-A

Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.

Evidence

The record for resident 1 contains a signed physician’s order, dated 04/03/2025, for the resident to have a urinalysis reflex due to the facility reaching out to the physician because the resident was having increased confusion and wanted to see if the resident needed a urinalysis due to this concern.
Interview with staff person 2 revealed to the licensing inspector (LI) during on-site inspection on 06/02/2025 that they were unable to say if a urinalysis had been done and/or provide the results to the LI of a urinalysis if one had been completed.

Plan of correction

All physician orders will be reviewed and signed by DHW or designee. DHW will ensure all orders have been followed. New Physician group has started at community and they send orders directly to the lab.

22VAC40-73-440-A

Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.

Evidence

The UAI for resident 1, dated 08/07/2024, contains documentation on page 2 that the resident requires their medications to the administered/monitored by a lay person – licensed nurse, registered medication aide; however, interview with staff person 3 revealed that the resident self-administers a multi-vitamin daily. Interview with resident 1 during on-site inspection on 06/02/2025 revealed to the licensing inspector (LI) that they do self-administer a multi-vitamin daily. Interview with staff persons 1, 2 and 3 revealed that the resident’s UAI is incorrect in regard to medication administration and that the resident can self-administer medication.
The UAI for resident 1, dated 08/07/2024, indicates that the resident requires mechanical help and human help supervision with mobility; however, interview with staff persons 1, 2 and 3 revealed that the resident only requires mechanical help with mobility and therefore the UAI is incorrect in regard to mobility.

Plan of correction

DHW/RCC/MCD will be retrained on UAI requirements by ED using UAI manual.

June 2, 2025Complaint survey4 violations

Inspection dates

06/02/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 06/02/2025 9:30 AM to 2:30PM 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 04/12/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 71 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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

22VAC40-73-870-E

Based on observation, the facility failed to ensure all furnishings, fixtures, and equipment, including toilets, shall be kept clean and in good repair and condition.

Evidence

At approximately 9:58AM during on-site inspection on 06/02/2025, a large area of a brown substance was observed by the licensing inspector (LI) and staff persons 1 and 2 inside of the resident’s toilet even after the toilet had been flushed.

Plan of correction

All Housekeepers will be retrained on proper cleaning procedures for resident apartments. Housekeepers will fill out completed room clean check sheets and give to DFO daily to review to ensure complete. Management staff will be assigned a group of apartments to monitor daily for cleanliness and will report to DFO any apartments with issues.

22VAC40-73-450-F

Evidence

The ISP in the record for resident 1, dated 03/07/2025, contains the following documentation, the resident requires mechanical and human physical assistance with bathing and that bathing is performed by others; that the resident requires no help with dressing and the resident requires mechanical and human supervision assistance with dressing; and that the resident requires mechanical help only, human supervision only, human physical assistance only, mechanical and human supervision, and mechanical and human physical assistance with transferring. Interview with staff person 1 revealed that the resident requires mechanical and human physical assistance with bathing, mechanical and human supervision assistance with dressing and mechanical help only with transferring.
The ISP contains documentation that 2 hour round checks by staff are required for the resident and that the resident will be checked on frequently for safety and toileting. Interview with staff person 1 revealed that this is not an identified need for the resident and should not have been included on the resident’s ISP.

Plan of correction

DHW/RCC/MCD will perform an audit of all ISP’s to ensure they have been updated at least every 12 months and with significant change. ED will retrain RCC/DHW/MCD on ISP’s.

22VAC40-73-450-E

Based on resident record review, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative.

Evidence

The ISP in the record for resident 1, dated 03/07/2025, has not been signed by the resident or the resident’s legal representative.

Plan of correction

DHW/RCC will conduct an audit of all ISP for signatures. Any ISP’s found to be missing signature will be flagged and a copy sent for signature and notation made on ISP.

22VAC40-73-460-H

Based on resident record review, facility documentation, and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired.

Evidence

The individualized service plan (ISP) in the record for resident 1, dated 03/07/2025, contains an identified need that the resident requires mechanical help and human physical assistance with bathing – staff are to provide physical assistance to transfer the resident in and out of the shower and to wash the resident’s upper and lower body while the resident uses a shower chair and available grab bars weekly as scheduled.
Interview with staff persons 1, 2 and 3 during on-site inspection on 06/02/2025 revealed to the licensing inspector (LI) that when staff assist the resident with a shower, staff are to fill out the form “Shower/laundry/linen & skin observation sheet” so that it is documented the resident received a shower. Shower/laundry/linen & skin observation sheets provided to the LI by staff persons 1, 2 and 3 indicate that the resident only received assistance with a shower on 04/02/2025, 04/09/2025, 04/16/2025, 04/19/2025, 04/23/2025 and 04/30/2025 during April 2025 and that the resident only received assistance with a shower on 05/28/2025 during May 2025.

Plan of correction

Care staff will be reeducated on proper documentation when/if resident refuses shower RCC/MCD/DHW will monitor shower sheets daily for refusals and reschedule bath if needed.

March 17, 2025Complaint survey5 violations

Inspection dates

03/17/2025, 03/21/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 03/17/2025 8:39AM t0 12:15PM & 03/21/2025 8:15AM to 11:30AM 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 03/14/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the compliant 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

22VAC40-73-470-A

Based on resident record review, resident interview and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.

Evidence

The hospital after visit summary in the record for resident 1, dated 03/06/2025 to 03/07/2025, states on page 1 that the resident had a scheduled primary care hospital follow-up visit appointment with Collateral 1 on Wednesday 03/12/2025 at 10:20AM and a statement to schedule an appointment with Collateral 1 as soon as possible for a visit in 1 week.
During an interview with the resident and staff persons 1 and 2 on 03/17/2025, the licensing inspector (LI) asked the resident if he went to this appointment. The resident stated that he did not go to the appointment because he did not know about the appointment until his family member received a call on 03/12/2025 wanting to know why the resident was not at the appointment.
The resident informed the LI and staff persons 1 and 2 that the facility will either give him a note about an upcoming appointment or verbally tell him about an upcoming appointment and he was not notified by anyone at the facility regarding this appointment. The resident stated that he takes transportation from the facility, the facility van, to his appointments and will meet his family member at the appointment. Staff persons 1 and 2 were unable to provide documentation that the resident had went to this appointment or that the resident had been to see Collateral 1 as of on-site inspection on 03/17/2025. Staff person 1 further stated that the facility does not provide transportation on Wednesdays for appointments.

Plan of correction

22VAC40-73-470A. Health care services The facility shall ensure, either directly or indirectly, that the health care service needs of residents are met. Plan of Correction: ED will send out letter to all Residents and RPs reminding them of Transportation policy and importance of bring all hospital discharge paperwork or paperwork from outside Physician visits to DHW immediately upon return to Community so that she has the information needed to ensure that the health care service needs of resident are met. Date to be Corrected:4/11/2025

22VAC40-73-450-C

Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the (i) uniform assessment instrument (UAI); (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.

Evidence

Resident 1 was admitted to the facility on 09/26/2023. The record for resident 1 contains documentation from Collateral 2, dated 09/11/2023 and 09/26/2023, and an order summary report from Collateral 2 signed by a physician, dated 09/25/2023, that the resident has diagnoses of alcohol dependence with withdrawal, alcohol abuse with withdrawal, and unspecified cirrhosis of liver. The record for resident 1 contains a progress note by Collateral 3, dated 09/28/2023, that the resident has a diagnosis of alcoholic cirrhosis of liver without ascites and a past medical history of alcohol abuse. The record for resident 1 contains a progress note by Collateral 4, dated 10/19/2023, that the resident has a diagnosis of severe alcohol abuse with history of withdrawal and associated seizures – recent admission with alcohol level of 0.326.
The ISPs in the record for resident 1, dated 09/11/2023 and 09/11/2024, do not contain any documentation that the resident has the aforementioned diagnoses. Interview with staff person 1 confirmed this is accurate.

Plan of correction

22VAC40-73-450-C: Individualized service plans C. The comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following: 1. Description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv} fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources; 2. A written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them; 3. When and where the services will be provided; 4. The expected outcome and time frame for expected outcome; 5. Date outcome achieved; and 6. For a facility licensed for residential living care only, if a resident lives in a building housing 19 or fewer residents, a statement that specifies whether the resident does or does not need to have a staff member awake and on duty at night. Plan of Correction: ISP for Resident #1 updated: 4/7/2025 DHW/RCC/MCD will complete an audit of all Resident ISP's and update all lSP's to ensure all pertinent diagnosis and related orders are on ISP. Date to be Corrected: 4/11/2025

22VAC40-73-460-A

Based on resident record review, resident interview and staff interview, the facility failed to ensure that the facility assumed general responsibility for the health, safety, and well-being of the resident.

Evidence

Resident 1 was admitted to the facility on 09/26/2023. The record for resident 1 contains documentation from Collateral 2, dated 09/11/2023 and 09/26/2023, and an order summary report from Collateral 2 signed by a physician, dated 09/25/2023, that the resident has diagnoses of alcohol dependence with withdrawal, alcohol abuse with withdrawal, and unspecified cirrhosis of liver. The record for resident 1 contains a progress note by Collateral 3, dated 09/28/2023, that the resident has a diagnosis of alcoholic cirrhosis of liver without ascites and a past medical history of alcohol abuse. The record for resident 1 contains a progress note by Collateral 4, dated 10/19/2023, that the resident has a diagnosis of severe alcohol abuse with history of withdrawal and associated seizures – recent admission with alcohol level of 0.326.
The record for resident 1 contains a signed physician’s order, dated 10/12/2023, that the resident may have 1 alcoholic beverage at dinner if desired to be served by staff member or at functions; however, staff person 1 informed the licensing inspector (LI) on 03/21/2025 that when the resident was hospitalized from 01/10/2024 to 01/12/2024, the hospital discharge orders/medications did not contain this order and therefore the order was discontinued. As of on-site inspection on 03/21/2025, the record for the resident does not contain an order that the resident may have alcohol. Staff person 1 confirmed this is accurate. In addition, the after-visit summary document from the resident’s 01/10/2024 to 01/12/2024 hospitalization, printed on 01/12/2024 at 1:54PM, contains information on page 2 of 10 that the resident is being discharged with Eliquis and for the resident to please refrain from any alcohol, ibuprofen, naproxen, or other anti-inflammatory medications while taking this medication. Staff person 1 revealed that the resident has continuously been taking Eliquis since he was admitted to the facility on 09/26/2023.
Numerous progress notes from Collaterals 3 and 5 from 10/02/2023 to 02/06/2025 in the record for resident 1 contain documentation that the resident has a history of alcohol abuse, alcohol use disorder, and has alcoholic cirrhosis.
The record for resident 1 contains an after-visit summary for a hospitalization from 11/02/2024 to 11/07/2024 that states that the resident was diagnosed with bleeding of the stomach and intestines. Page 12 of 14 of the after-visit summary contains a statement of gastrointestinal bleeding discharge instructions and documentation of “what care is needed at home?” that states the resident is to avoid drinking beer, wine, and mixed drinks (alcohol).
During an interview with staff person 3 on 03/17/2025, staff person 3 informed the LI that the resident has been attending “Happy Hour”, to his knowledge, every Friday since he has been employed at the facility since September 2024. Staff person 3 stated that the resident had started asking if he can have more alcoholic drinks and if staff person 3 could purchase him alcohol. Staff person 3 stated that he asked staff person 1 how many alcoholic beverages the resident could have and staff person 1 stated no more than 3 during “Happy Hour”; staff person 3 stated that each drink consists of 2 ounces of liquor and the rest Coke. In addition, when staff person 3 asked staff person 1, staff person 1 informed staff person 3 that he could purchase the resident alcohol; however, the resident would have to give his own money to staff person 3 to purchase alcohol. (Due to limited space allowed by the VDSS computer licensing system, the remainder of this volitation notice is on a separate document and available upon request.)

Plan of correction

22VAC40-73-460A. Personal care services and general supervision and care. The facility shall assume general responsibility for the health, safety, and well-being of the residents. Plan of Correction: DHW/RCC/MCD will obtain Physician orders and update ISP's for all Residents who wish to consume alcoholic beverages in their apartments or during community functions. Any Residents or RP's with complaints of Resident Rights being violated will be referred to the Local Ombudsman. Date to be Corrected:4/11/2025

22VAC40-73-660-B

Based on resident record review, resident interview and staff interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.

Evidence

The UAI for resident 1, reassessment date 09/11/2024, contains documentation on page 2 that the resident can self-administer Ozempic but also requires their medications to be administered/monitored by a lay person; registered medication aide (RMA), registered nurse (RN), and/or licensed practical nurse (LPN). The March 2025 medication administration record (MAR) indicates that the facility administers all the other medications the resident is prescribed.
Interview with staff person 2 revealed that staff persons 4 and 5 did a room sweep of resident 1’s room while he was at the hospital during 03/06/2025 and 03/07/2025 and found a package of CBD gummies. Staff person 2 stated that when the resident came back from the hospital, she gave the CBD gummies back to resident 1. During an interview with resident 1 on 03/17/2025, resident 1 informed staff persons 1, 2 and the licensing inspector (LI) that he does have CBD gummies and that he is taking the CBD gummies.
The record for resident 1 does not contain an order that the resident may keep/maintain CBD gummies in their room and that he is capable of self-administering CBD gummies. Interview with staff person 1 confirmed this is accurate.

Plan of correction

STANDARD: 22VAC40-73-660B. Storage of medications. A resident may be permitted to keep his own medication in an out-of-sight place in hls room if the UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. This does not prohibit the facility from storing or administering all medication and dietary supplements. Plan of Correction: UAI for Resident #1 has been updated DHW/RCC/MCD will audit and update all Resident charts to ensure UAl's reflect current ability of resident to self-administer medications or the need to have medications administered by lay person. Date to Be Corrected By: 4/11/2025

22VAC40-73-650-F

Based on resident record review and staff interview, whenever a resident is admitted to a hospital for treatment of any condition, the facility failed to obtain new orders for all medications and treatments prior to or at the time of the resident’s return to the facility and the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.

Evidence

The record for resident 1 contains documentation that the resident was hospitalized from 03/06/2025 to 03/07/2025. The hospital paperwork states that there is a change to how the resident is to take Levetiracetam (the medication strength changed and how much the resident is to take), to stop taking Eliquis 5MG and to ask how to take Polyethylene Glycol powder (Miralax).
During on-site inspection on 03/17/2025, staff persons 1 and 2 revealed that the resident had not been to see his primary care physician, Collateral 1, and staff persons 1 and 2 were unable to produce any documentation that Collateral 1 had been contacted about the resident’s 03/06/2025 to 03/07/2025 hospitalization and the medication orders from the hospital.

Plan of correction

22VAC40-73-650F. Physician's or other prescriber's order. Whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders Plan of Correction: Hospital record for Resident #1 was faxed to MD and Resident saw MD on 3/20/2025. All clinical staff will be re-educated that when a Resident returns from the Hospital or an outside Physician, all hospital paperwork must immediately be faxed to the Residents PCP and documented that it was sent. ED will send out notification to all Residents and RP's to educate them that when a resident goes to the hospital or is seen by a Physician outside of the Community, all paperwork from the visit needs to be given to DHW to copy and review upon return to Community. Date to be corrected by:4/11/2025

March 17, 2025Inspection0 violations

Inspection dates

03/17/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 03/17/2025 8:39AM to 12:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 10, 2025Complaint survey0 violations

Inspection dates

02/10/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 02/10/2025 8:40AM to 9:20AM 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 02/06/2025 regarding allegations in the areas of: administration and administrative services & resident care and related services Number of residents present at the facility at the beginning of the inspection: 70 Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 14, 2025Inspection14 violations

Inspection dates

01/14/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

To ensure the facility has a thorough understanding of the standards, the licensing inspectors had a discussion with the administrator regarding standards 22VAC40-73-680-K and 22VAC40-73-440-A.

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/14/2025 8:00AM to 5:20PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: medication administration, medication cart audits, noon-time meal, activity 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

22VAC40-73-1100-A

Based on resident record review and staff interview, the facility failed to obtain written approval of one the required persons prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.

Evidence

The record for resident 3, admission date 7/18/2024, contained an Approval for Placement in Special Care Unit with documentation of the required persons written approval on 1/10/2025, and there were no written approvals prior to that date.
During an interview with two licensing inspectors (LIs) and staff person 2, staff person 2 confirmed the record for resident 3 to be current.

Plan of correction

The MCD/designee will perform an audit of all Resident files in the secured unit to ensure all Residents have the Approval for Placement in Special Care Unit form in their file. Any found to be missing will be immediately obtained and placed in file. DHW/MCD will review all admission paperwork prior to resident arrival and admission will be postponed if any required paperwork is missing.

22VAC40-73-720-A

Based on resident record review and staff interview, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility when all requirements are met.

Evidence

The record for resident 1 contained a signed Durable Do Not Resuscitate Order, dated 5/22/2024.
Resident 1’s record contained the most current Individual Service Plan (ISP) dated, 4/12/2024, with documentation that resident 1 is a Full Code with staff to follow directions and procedures for CPR as needed.
During an interview with the two licensing inspectors (LIs) and staff person 2, staff person 2 confirmed the record for resident 1 to be current.

Plan of correction

DHW/MCD/RCC/Designee will perform a complete audit of Resident files for Code status to ensure Code status is in each file. DHW/MCO/RCC/designee will perform an audit of all Resident ISP's to ensure code status on ISP matches Resident code status choice.

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated after a resident falls.

Evidence

The record for resident 4 contains documentation that the resident had a fall on 12/10/2024 and 12/12/2024; however, the resident’s fall risk assessment document does not contain evidence that the fall risk rating was updated to reflect the 12/10/2024 fall. Interview with staff person 1 on 01/16/2024 confirmed this is accurate.

Plan of correction

DHW/MCD/RCC/Designee will perform a complete audit of Resident files to ensure all Resident falls have had an updated Fall Risk Assessment completed and update any found to be missing.

22VAC40-73-260-A

Based on staff record review and staff interview, the facility failed to ensure each direct care staff member shall maintain current certification in first aid.

Evidence

The record for staff person 4 contained a certificate of complete, dated 07/20/2022, in CPR/AED/First Aid; however, the certificate contains documentation that the staff person’s certification is only valid for two years until 07/20/2024. Interview with staff persons 1 and 2 revealed that this is the most current certification for the staff person.
The record for staff person 7, date of hire 7/31/2024, did not contain any documentation for certification in First Aid.

Plan of correction

The Business Office Manager/ designee will perform a complete audit of all employee charts. Any employee found to be out of compliance with CPR/First Aid/AED will be required to take Mandatory CPR/First Aid/ AED class provided through our Pharmacy or obtain on their own. BOM will start using a check sheet when putting new Employee files together to ensure all required documents are in file.

22VAC40-73-1090-A

Based on resident record review and staff interview, the facility failed to ensure that prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry) and the assessment shall be in writing and shall include all of the requirements.

Evidence

The record for resident 5, admission date 12/30/2024, did not contain an assessment of serious cognitive impairment with all requirements.
During an interview with two licensing inspectors (LIs) and staff person 2, staff person 2 confirmed the record for resident 5 to be current.

Plan of correction

DHW/MCD/designee will review all admission paperwork prior to Resident arrival using a check sheet for required documentation for Resident file. Any documents found incomplete will be sent back to the provider or RP to complete. Admission will be postponed if any required paperwork is missing.

22VAC40-73-680-D

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

The record for resident 3 contains a signed physician’s order, dated 12/9/2024, with documentation to DC (discontinue) PRN Lorazepam, Lorazepam 0.5mg po Q12 x 14 days. The January 2025 Medication Administration Record (MAR) for resident 3 contains documentation for Lorazepam 0.5mg Tablet, Take one tablet by mouth daily as needed for agitation, anxiety, or shortness of breath. During the medication cart audit, the two licensing inspectors (LIs) observed this prescription to be available on the medication cart for administration to resident 3.
The record for resident 4 contains a signed physician’s order, dated 12/19/2024, to discontinue Melatonin. The January 2025 medication administration record (MAR) for the resident contains documentation that the resident has been administered Melatonin daily at 9:00PM from 01/01/2025 to 01/13/2025 and during the medication cart audit, the two LIs observed this prescription in the cart for the resident.

Plan of correction

A Mandatory Clinical staff meeting will be held 1/29/2025 to review the Medication Management Plan. All orders will be faxed to Pharmacy by the RCC/MCD or designee. Faxed confirmation sheet will be attached to the order and given to the DHW. The DHW or designee will ensure the order has been added or deleted from the Mar and approved in QuickMar. DHW or designee will pull any discontinued medication from the cart and return to pharmacy. The fax confirmation sheet will be initialed, and order will be filed in the Resident chart.

22VAC40-73-450-D

Based on resident record review and staff interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident and the services provided by each shall be included on the individualized service plan (ISP).

Evidence

Interview with staff person 2 revealed that resident 4 is currently receiving hospice services. Staff person 2 stated that a certified nursing assistant (CNA) comes out two times a week to give the resident a shower and a nurse comes out one to two times a week to visit the resident; however, these services are not included on the identified need of hospice on the resident’s ISP dated 11/11/2024.

Plan of correction

DHW/RCC/MCD will perform an audit of ISP's of all residents receiving Hospice or Home Health to ensure that all services on the Resident's ISP. Any services found to be missing will be added to the Resident's ISP.

22VAC40-73-50-B

Based on resident record review and staff interview, the facility failed to ensure that written acknowledgment of the receipt of the disclosure by the resident or the resident’s legal representative is retained in the resident's record.

Evidence

The record for resident 5, admission date 12/30/2024, and the record for resident 6, admission date 01/01/2025, did not contain a written acknowledgement receipt of the disclosure statement.
During an interview with the two licensing inspectors (LIs) and staff person 2, staff person 2 confirmed the records for residents 5 and 6 were current.

Plan of correction

The Business Office Manager/ designee will perform a complete audit of all Resident Business Office files. BOM or designee will obtain all required documents that are found missing and place in the Business Office files. BOM will start using a check sheet when putting Business Office files together to ensure all required documents are in file.

22VAC40-73-640-A

Based on an audit of medication carts and facility policy review, the facility failed to implement its medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.

Evidence

The facility’s medication management plan provided by staff person 1 via email on 01/15/2025 states on page 365 that any time keys are passed, both staff members will count all controlled substances and sign-off on the controlled substance shift count form.
The January 2025 “Narcotic Count Key Transfer Sheet” for the memory care medication cart and medication cart “3” contained multiple days and times that on-coming and/or out-going staff did not sign.

Plan of correction

A Mandatory Clinical staff meeting will be held 1/29/2025 to review the Medication Management Plan. DHW or designee will review the narcotic count sheets every morning. If a hole is found on the narcotic count sheet, the DHW or designee will count narcotics with the current RMA and call the staff member who did not count narcotics into facility to have count conducted and signed.

22VAC40-73-270-4

Based on staff record review and staff interview, the facility failed to ensure direct care staff shall have refresher training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states at least annually or more often as needed.

Evidence

Interview with staff person 1 revealed that the facility has in care residents who have a history of aggressive behavior or of dangerously agitated states.
The record for staff person 6, date of hire 07/12/2022, does not contain documentation of the staff person having aggressive behavior training for the training year 07/12/2023 to 07/11/2024. Interview with staff person 1 confirmed this is accurate.

Plan of correction

The Business Office Manager/ designee will perform a complete audit of all employee charts. Any employee found to be out of compliance with mandatory training requirements will be required to take the missing training or be pulled off the schedule until it is completed. BOM will start using a check sheet when putting new Employee files together to ensure all required documents are in file.

22VAC40-73-530-C

Based on observation during a tour of the facility’s safe, secure unit and staff interviews, the facility failed to ensure to provide freedom of movement for the residents to their personal spaces and shall not lock resident out of or inside their rooms.

Evidence

While the licensing inspectors (LIs) were performing a walk-through of the facility’s safe, secure unit, the LIs observed that multiple residents’ rooms were locked.
Interview with staff persons 1 and 2 revealed to the LIs that they have received family requests for residents’ doors to be locked due to other residents often wandering into rooms and taking items from the rooms.
The door to residents 7, 8 and 9 rooms were locked and interview with staff person 2 revealed that these residents may or may not have keys to their rooms; however, they would not know how to use the key to unlock their doors to get into their room.

Plan of correction

A letter will be sent to RP's of all residents in the secured unit explaining regulation 22VAC40-73-50-B. Staff in the secured unit will monitor apartment door throughout the day to ensure that no resident is locked out of their room.

22VAC40-73-1180-B

Based on observation during a tour of the facility’s safe, secure unit, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials of objects shall be inaccessible to the resident except under staff supervision.

Evidence

At approximately 8:33AM, the licensing inspector (LI) noted that the door to the cabinet underneath the sink in the facility’s safe, secure unit common area was unlocked and contained a metal spray container of Sysco classic grill and griddle cooking spray, an opened bottle of Lander Xplosion refreshing mint mouthwash and a plastic spray bottle of Zep commercial professional sprayer cleaner. These items were brought to the attention of staff person 2 and staff person 2 confirmed that the items should not have been in an unlocked cabinet.

Plan of correction

The Memory Care Director (MCD)/designee will add room sweeps each shift to staff assignment sheet in the secured unit. Staff will remove any object found during room sweeps that could be harmful to a resident and give to the Memory Care Director or designee to secure in an area inaccessible to the resident. Staff will document room sweeps completed on the resident rounds sheet and MCD/designee will review daily.

22VAC40-90-40-B

Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.

Evidence

The record for staff person 5, date of hire 9/1/2024, did not contain a criminal history record report. During an interview with the two licensing inspectors (LIs) and staff person 2, staff person 2 confirmed staff person 5’s record to be current.

Plan of correction

The Business Office Manager/ designee will perform a complete audit of all employee charts. The BOM or designee will obtain any missing required documentation and place in the employee file. BOM will start using a check sheet when putting new Employee files together to ensure all required documents are in file.

22VAC40-73-320-A

Based on resident record review and staff interview, the facility failed to ensure that a physical examination with all required information was obtained within 30 days preceding admission for a resident.

Evidence

The record for resident 5, admission date 12/30/2024, contained a Report of Resident Physical Examination, dated 12/27/2024 with no documentation of the resident’s address, telephone, height, a statement that the individual does not have any of all the conditions or care needs prohibited by 22VAC40-73-310 H, a statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter, diagnosis or significant problems, and a statement that specifies whether the individual is or is not capable of self- administering medication, and results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
During an interview with two licensing inspectors (LIs) and staff person 2, staff person 2 confirmed the record for resident 5 to be current.

Plan of correction

DHW/MCD/designee will review all admission paperwork prior to resident arrival using check sheet for Business Office file and admission will be postponed if any required paperwork is missing. Any documents found incomplete will be sent back to provider or RP to complete.

January 14, 2025Complaint survey1 violation

Inspection dates

01/14/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 01/14/2025 8:00AM to 5:20PM 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 12/20/2024 regarding allegations in the areas of: personnel & resident care and related services Number of residents present at the facility at the beginning of the inspection: 70 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 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

22VAC40-73-640-A

Based on resident record review, staff interview and facility policy review, the facility failed to implement its medication management plan in regard to methods to ensure that each resident’s prescription medications ordered for the resident are filled in a timely manner to avoid missed dosages.

Evidence

The facility’s medication management plan provided by staff person 1 on 01/14/2025 states on page 24 of 61 that medications will be ordered in a timely manner by the community, all necessary information regarding the medication order will be faxed to the pharmacy and medications with delivery in a timely manner and on page 29 of 61 that when an order is received a copy of the order will be faxed to the dispensing pharmacy and the community will assure that the fax was received, will assure that the order is transcribed to the resident’s medication administration record, and will assure that the medication will be available for administration for the next scheduled dose, unless otherwise documented.
The record for resident 1 contains a signed physician’s order on facility letterhead, dated 11/14/2024, that states “Start Depakote 125mg po BID”.
The November 2024 medication administration record (MAR) for resident 1 contains documentation that the resident did not receive the first dose of this medication until 11/21/2024 at 9:00AM.
During an interview with staff person 1 on 01/14/2025, staff person 1 was unable to give an exact reason why the resident did not receive the first dose of this medication until 11/21/2024 at 9:00AM.

Plan of correction

We will conduct a Mandatory Clinical Staff meeting and review the Medication Management Plan. I have hired a DHW who started 1/20/25. A copy of all orders and fax confirmation will be given to DHW or designee. DHW will ensure medication is transcribed to the Resident’s MAR and ensure medication will be available for administration for the next scheduled dose, unless otherwise documented.

December 19, 2024Complaint survey5 violations

Inspection dates

12/19/2024, 01/14/2025

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/19/2024 9:07AM to 12:30PM and 01/14/2025 8:00AM to 5:20PM 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 12/02/2024 regarding allegations in the areas of: admission, retention and discharge of residents & resident care and related services. Number of residents present at the facility at the beginning of the inspection: 70 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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

22VAC40-73-440-A

Based on resident record review and staff interview, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110) and the UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.

Evidence

The UAI for resident 1, dated 09/04/2024, does not contain documentation as to whether the resident requires assistance with eating/feeding. Interview with staff person 1 revealed that the resident does not require assistance with eating/feeding.

Plan of correction

Uniform assessment instrument (UAI) A.All residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition Plan of Correction: DHW/Designee will perform an audit of all UAl's to ensure they are completely fill out. Any found to have documentation missing will be updated. Date to be Corrected: February 21,2025

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility.

Evidence

The record for resident 1 contains a progress note by Collateral 4, dated 09/26/2024, that the resident was seen on this day to review doppler results and discuss concerns about edema and wounds on bilateral lower extremities and that a venous doppler was requested by home health to evaluate the need for wraps or una boots. The same progress note by Collateral 4 also states that the resident has an upcoming appointment with Collateral 2 for a procedure related to his lower extremities. Interview with staff persons 1 and 2 revealed to the LI on 12/19/2024 that the resident informed the facility that he did not want to be seen by Collateral 4 anymore and that he was going to see Collateral 3 instead; therefore, the record for the resident does not contain any additional progress notes by Collateral 4 past 09/30/2024.
During an interview with the licensing inspector (LI), Collateral 1 and staff persons 1 and 2 on 12/19/2024, Collateral 1 stated that the resident had been going to appointments at a wound care clinic once a week and that the resident took himself to these appointments. 3. During on-site inspection on 01/14/2024, staff person 2 contacted Collateral 2 and obtained documentation of appointments the resident had at Collateral 2 on 10/02/2024, 10/08/2024, and 10/16/2024 due to swelling in his legs. Documentation indicates during the 10/02/2024 visit, the resident’s legs were wrapped, during the 10/08/2024 visit, the resident’s legs didn’t need to be rewrapped but Collateral 2 placed the resident in his Velcro compression garments that are to be worn daily from morning until bedtime, and during the 10/16/2024 visit, the resident was informed to continue with Velcro compression garments to his BLE and feet, wear daily and that Collateral 2 will see the resident again as needed. Staff person 2 confirmed that the facility was unaware of resident 1 going to appointments at Collateral 2 and unaware of the contents of the documentation from Collateral 2 until they were received on 01/14/2025.
Additionally, during on-site inspection on 01/14/2024, staff person 2 contacted Collateral 3 and obtained documentation of appointments the resident had at Collateral 3 on 10/03/2024 and 11/05/2024. Documentation by Collateral 3, dated 10/03/2024, contains documentation that the resident stated he needed a referral for an MRI of his back due to having two falls since July 2024 and the resident stated since July’s fall he cannot stand now and he fell off a bed at the facility he is currently residing at because he said he was left on the side of the bed without any help. The resident also stated that he had not had a bowel movement in five days. The documentation includes that Collateral 3 prescribed polyethylene glycol and docusate sodium for constipation and made a referral for radiology and imaging. Documentation by Collateral 3, dated 11/05/2024, contains documentation that the resident currently has a urinary tract infection which he is on an antibiotic for, and the documentation states the resident will need a repeat urinalysis 72 hours after completing the antibiotic. The resident also stated he currently has a sinus infection that has been going on for about a week. The documentation states the plan for the resident is to avoid carbonated beverages and increase fluid intake. The resident also stated on 11/05/2024 he needs an order sent to the facility he is currently residing at to have miracle cream applied to bed sore on his buttock, left side, which he was unable to show the area while at Collateral 3 due to not being able to transfer to the clinic exam table or stand, and requested an order for the facility wound nurse to assess the area. (additional documentation would not fit on this notice)

Plan of correction

Resident records E. All resident records shall be kept current, retained at the facility, and kept in a locked area, except that information shall be made available as noted in subsection F of this section. Plan of Correction: ED will send a letter to all residents and Responsible Parties reminding them that when the Resident sees an outside Physician or has an ER visit or hospitalization a copy of the paperwork needs to be given to the DHW so that she can follow up on any new or changed orders or treatments. DHW will request the information from the treating Physician if paperwork is not brought to her by Resident or Responsible party. Date to be Corrected: February 21,2025

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated after a resident has a fall.

Evidence

The uniform assessment instrument (UAI) for resident 1, dated 09/04/2024, indicates the resident is assisted living level of care.
The record for resident 1 contains a post fall investigation report completed by staff person 3, dated 09/21/2024, that she was informed by care managers that they were trying to get the resident out of the bed for breakfast on 09/21/2024 and that the resident would not help them to get up and that the resident kept throwing himself backwards. Staff person 3 went to the resident’s room to help and found the resident on the floor sitting in front of his electric wheelchair. Local EMS was then called to the facility, and they got the resident up out of the floor.
The record for the resident does not contain an updated fall risk rating for the fall. Interview with staff person 2 confirmed this is accurate.

Plan of correction

Standard#: 22VAC40-73-325B Fall risk rating B. The fall risk rating shall be reviewed and updated under each of the follow·ing circumstances: 1'. At least annually; 1. When the condition of the resident changes; and 2. After a fall Plan of Correction DHW/Designee will complete an audit of all Resident charts for fall risk rating and ensure they are current. Date to be Corrected: February 21,2025

22VAC40-73-450-F

Evidence

The ISP for resident 1, dated 09/25/2024, indicates that the resident requires mechanical and human physical assistance with bathing and that direct care staff are to provide physical assistance to transfers in and out of shower and to wash the resident’s upper and lower body while the resident uses a shower chair and available grab bars. Interview with staff person 1 revealed that direct care staff were performing a bed bath for the resident since they were unable to get the resident in and out of the shower due to not having the appropriate transfer device. Staff person 1 also stated that direct care staff were giving the resident a bed bath daily due to the resident having incontinence issues. Staff person 1 confirmed that the resident’s ISP had not been updated to reflect this information.
The ISP for the resident, dated 09/25/2024, indicates that the resident requires mechanical and human physical assistance with toileting and that the resident will toilet with the assistance of grab bars, walker and a toilet chair with physical assistance to dress/undress, toilet and perform peri care. Interview with staff person 1 revealed that the resident did not use a walker and therefore should not have been included on the resident’s ISP and that the ISP for the resident should have included information that the resident used a urinal at night and also during the day.
The ISP for the resident, dated 09/25/2024, indicates that the resident requires mechanical and human physical assistance with transferring and that the resident will transfer with the assistance of chair arms and a sliding board as well as human physical assistance to transfer. Interview with staff person 1 revealed that the ISP should have also included information that the resident required the assistance of two direct care staff at times for transferring.
Interview with staff person 1 revealed that the resident had an electric wheelchair he used for mobility; however, this identified need was not on the resident’s ISP dated 09/25/2024.
The record for resident 1 contains occupational therapy notes; however, the resident’s ISP dated 09/25/2024, does not include information that the resident was receiving occupational therapy. Interview with staff person 1 confirmed this is accurate.

Plan of correction

Individualized service plans F. Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident's condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, healthcare providers, qualified mental health professionals, or other persons. Plan of Correction: DHW/Designee will complete an audit of all lSP's/UAl's to ensure they correctly reflect Residents' needs and match Date to be Corrected: February 21,2025

22VAC40-73-460-H

Based on resident record review, staff interview and collateral interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met including assistance or care with bathing at least twice a week, but more often if needed or desired.

Evidence

Resident 1 was admitted to the facility on 09/06/2024. The uniform assessment instrument (UAI), dated 09/04/2024, for the resident indicates the resident requires mechanical help and human physical assistance with bathing. The preliminary care plan for the resident, dated 09/06/2024, indicates the resident requires staff assistance with bathing and the comprehensive individualized service plan (ISP) for the resident, dated 09/25/2024, indicates the resident requires mechanical and human physical assistance with bathing – care staff are to provide physical assistance to transfer in and out of shower and to wash resident’s upper and lower body while the resident uses a shower chair and available grab bars in bathroom weekly as needed.
Interview with staff person 1 on 12/19/2024 revealed that Collateral 1 stated the resident could not get in and out of the shower due to not having the appropriate lift. Collateral 1 informed the licensing inspector (LI) during an interview on 12/19/2024 that when the resident first arrived at the facility, there was a Hoyer Lift for the resident; however, it was not the appropriate equipment for the resident. A sit-to-stand lift was then ordered for the resident and arrived at the facility 3-4 weeks prior to the resident moving out of the facility and that direct care staff were trained to use the sit-to-stand lift.
Interview with staff person 1 revealed that direct care staff were performing a bed bath for the resident since they were unable to get the resident in and out of the shower due to not having the appropriate transfer device. Staff person 1 also stated that direct care staff were giving the resident a bed bath daily due to the resident having incontinence issues.
Interview with staff persons 1 and 2 revealed that the facility utilizes the document “Shower/laundry/linen & skin observation sheet” as documentation of when a resident receives a shower. The record for the resident only contains documentation that the resident received a bed bath on 09/20/2024, 09/24/2024, 10/04/2024, 10/08/2024, 10/15/2024, 10/24/2024, 10/19/2024, 11/08/2024 and 11/22/2024. Interview with staff person 1 confirmed this is accurate.

Plan of correction

Standard#: 22VAC40-73-460-H.1.a: Personal care services and general supervision and care. H. The facility shall ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: 1. The activities of daily living: a. Bathing - at least twice a week, but more often if needed or desired. Plan of Correction DHW/Designee will complete an audit of all lSP's/UAl's to ensure they correctly reflect Residents' needs and match. DHW/Designee will add a section to the shower sheet that reflects when a Resident is cleaned after incontinence episodes for staff to sign off. Date to be Corrected: February 21,2025

November 12, 2024Inspection1 violation

Inspection dates

11/12/2024

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: 11/12/2024 8:45AM to 10:45AM 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 10/24/2024 regarding allegations in the areas of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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

22VAC40-73-680-D

Based on resident record review and facility self-reported incident, medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The licensing inspector (LI) received a self-reported incident via email on 10/24/2024 from staff person 3 that staff person 1 was orienting a new employee, staff person 2, on the safe, secure unit regarding medication administration. Staff person 1 pointed to resident 1 for staff person 2 to give medication to and staff person 2 stood next to resident 1 and asked staff person 1 if resident 1 was the correct resident and staff person 1 stated yes. Staff person 2 administered lorazepam 0.5MG and Seroquel 25MG to resident 1 and then staff person 1 informed staff person 2 that those medications were supposed to be administered to resident 2. Interview with staff person 3 on 11/12/2024 confirmed this information is accurate.

Plan of correction

Staff member #2 was immediately moved to train on the medication cart with a different RMA. Staff member #2 will be re-educated on medication administration; will complete a 4 hr medication administration course, and will complete Relias courses on avoiding medication errors and orienting other RMA's utilizing safe identification practices.

November 12, 2024Inspection2 violations

Inspection dates

11/12/2024

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: 11/12/2024 8:45AM to 10:45AM 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 10/20/2024 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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

22VAC40-73-450-A

Based on resident record review and staff interview, the facility failed to ensure a preliminary plan of care shall be signed and dated by the resident or his legal representative.

Evidence

The preliminary care plan for resident 1, dated 10/11/2024, is not signed and dated by the resident or the resident’s legal representative. Interview with staff person 1 confirmed this is accurate.

Plan of correction

RCC and MCD, and designee will be re-educated on the ISP development and regulations by ED

22VAC40-73-440-D

Based on resident record review and staff interview, the facility failed to ensure that private pay uniform assessment instruments (UAIs) shall be completed as required by 22VAC30-110.

Evidence

The preliminary care plan for resident 1, dated 10/11/2024, includes information that the resident is verbally and physically aggressive/abusive; however, the UAI for resident 1, dated 10/08/2024, does not indicate that the resident is abusive/aggressive/disruptive.
Interview with staff person 1 revealed that the preliminary care plan is correct and the UAI should have included the resident is abusive/aggressive/disruptive.

Plan of correction

RCC and MCD, and designee will be re-educated on the UAI development and regulations by ED

November 12, 2024Inspection0 violations

Inspection dates

11/12/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 17, 2024Complaint survey6 violations

Inspection dates

09/17/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: 09/17/2024 9:05AM to 1:15PM 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 08/28/2024 regarding allegations in the areas of: resident care and related services & additional requirements for facilities that care for residents with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 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 & additional requirements for facilities that care for resident with serious cognitive impairments 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

22VAC40-73-520-I

Based on staff interview and facility document review, the facility failed to ensure the schedule of activities for the past two years shall be kept at the facility.

Evidence

During on-site inspection on 09/17/2024, the only schedule of activities that staff person 1 could locate at the facility were for the months March 2024, June 2024, August 2024 and September 2024. Interview with staff person 1 confirmed that this is accurate.

Plan of correction

The schedule of activities for the past two years shall be kept at the facility. Plan of Correction: A copy of each month’s Activity calendar shall be kept in a notebook in Activity Director’s office.

22VAC40-73-1120-F

Evidence

Interview with staff person 1 revealed that there was not a designated staff person responsible for managing or coordinating the structed activities program for the facility’s safe, secure unit from the end of July 2024 to 09/01/2024.

Plan of correction

Based on staff interview, the facility failed to ensure there shall be a designated staff person responsible for managing or coordinating the structured activities program and the staff person shall be on site in the special care unit at least 20 hours a week, shall maintain personal interaction with the residents and familiarity with their needs and interests, and shall meet at least one of the qualifications in 22VAC40-73-1120-F-1 through 5. Plan of Correction: Activity Director hired for special care unit. She will receive the required training approved by the Virginia Department of Social Service’s Division of Licensing Programs and meets the requirements of 22VAC 40-73-1120 F 5 of Standards for Licensed Assisted Living Facilities within 6 months.

22VAC40-73-620-A

Based on documentation review and resident record review, the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet, and special diets may also be referred to using terms such as medical nutrition therapy or diet therapy.

Evidence

The record for resident 2 contains a report of resident physical examination, dated 09/15/2023, that the resident is to receive a diabetic diet and a physician’s diet order, dated 09/15/2023, that the resident is prescribed a diabetic diet.
During observation of the facility’s kitchen, the licensing inspector (LI) and staff persons 1 and 2 observed on the kitchen’s bulletin board that the resident is a diabetic. Interview with staff person 2 confirmed that the resident is to receive a diabetic diet.
The document on-site oversight on medical nutrition therapy, dated 04/22/2024, completed by Collateral 1, does not include information that resident 2 was part of Collateral 1’s oversight of prescribed special diets on 04/22/2024. Interview with staff person 1 confirmed that resident 2 should have been part of Collateral 1’s oversight on 04/22/2024.

Plan of correction

The facility will ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet, and special diets may also be referred to using terms such as medical nutrition therapy or diet therapy. Plan of Correction: RCC’s will complete a complete audit of all resident diet orders to ensure all diets are correct. Facility will request dietitian visit to have all special diets reviewed.

22VAC40-73-450-C

Based on resident record review, observation and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the (i)UAI; (ii) admission physical examination: (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.

Evidence

The record for resident 2 contains a report of resident physical examination, dated 09/15/2023, that the resident is to receive a diabetic diet and a physician’s diet order, dated 09/15/2023, that the resident is prescribed a diabetic diet.
During observation of the facility’s kitchen, the licensing inspector (LI) and staff persons 1 and 2 observed on the kitchen’s bulletin board that the resident is a diabetic. Interview with staff person 2 confirmed that the resident is to receive a diabetic diet.
The ISP for resident 2, dated 09/11/2023, contains documentation that the resident is to be served a regular diet; resident will have at least three well-balanced meals, served at regular intervals, provided daily with the opportunity for snacks and hydration between meals and facility will prepare. The resident’s ISP does not contain documentation that the resident is to be served a diabetic diet.

Plan of correction

the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the (i)UAI; (ii) admission physical examination: (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Plan Of Correction: ED or designee will compare ISP to current MD orders to ensure all orders match and are included prior to signing ISP.

22VAC40-73-520-E

Based on staff interview, the facility failed to ensure in a facility licensed for both residential and assisted living care, there shall be at least 14 hours of scheduled activities available to residents each week for no less than one hour each day.

Evidence

Interview with staff person 1 revealed that there was not at least 14 hours of scheduled activities available to residents each week in the facility’s assisted living section from the end of July 2024 to 09/01/2024.

Plan of correction

In a facility licensed for both residential and assisted living care, there shall be at least 14 hours of scheduled activities available to residents each week for no less than one hour each day. Plan of Correction: Activity Director hired and will provide at least 14 hours of scheduled activities to residents each week for no less than one hour each day.

22VAC40-73-450-A

Based on resident record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.

Evidence

The record for resident 1 contains a preliminary plan of care dated 07/02/2024 which was completed longer than seven days prior to the resident’s date of admission on 08/01/2024.

Plan of correction

A preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare on or within seven days prior to the day of admission. Plan of Correction: ED or designee will monitor preliminary plans of care to ensure that they are completed within the 7 day time frame.

September 17, 2024Inspection2 violations

Inspection dates

09/17/2024

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: 09/17/2024 9:05AM to 1:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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

22VAC40-73-70-A

Based on resident record review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

The record for resident 2 contains documentation that the resident was sent out to the hospital on 07/31/2024 at 3:30PM due to two falls within a short period of time and the resident was complaining of lower back pain.
Emergency department after visit summary, dated 07/31/2024, contains documentation that the reason the resident was being seen at the emergency department was due to falling and head injury and the resident was diagnosed with acute midline thoracic back pain and lumbar back pain.
As of on-site inspection on 09/17/2024, the aforementioned incident involving resident 2 has not been reported to the regional licensing office.

Plan of correction

The facility is to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Plan of Correction: ED or designee will re-educate staff on the importance of reporting incidents within required time frame. ED or designee will be responsible for ensuring that all incidents are reported to licensing within required time frame. ED or designee will ensure that a formal report from incident 7/31/2024 is sent to licensing office.

22VAC40-73-680-D

Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 1 contains a physician’s order, dated 06/12/2024, for artificial tears four times daily. The August 2024 medication administration record (MAR) for the resident contains documentation that the resident did not receive artificial tears on 08/01/2024 at 4:00PM through 08/03/2024 at 8:00AM due to pending delivery. The record for resident 1 contains a physician’s order, dated 06/12/2024, for brimonidine eye drops three times daily. The August 2024 MAR for the resident contains documentation that the resident did not receive brimonidine eye drops on 08/01/2024 at 4:30PM due to pending delivery. The record for resident 1 contains a physician’s order, dated 07/01/2024, for colace 100MG at bedtime daily. The August 2024 MAR for the resident contains documentation that the resident did not receive colace 100MG on 08/19/2024 and 08/20/2024 at 8:00PM due to pending delivery.

Plan of correction

The facility is to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions. Plan of Correction: All RMA’s will be re-educated on procedure for re-ordering medications and procedure when medications are not available

July 16, 2024Inspection1 violation

Inspection dates

07/16/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 07/16/2024 8:45AM until 10:15AM 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 05/29/2024 regarding allegations in the areas of: personnel and resident care & related services Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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

22VAC40-73-70-C

Based on documentation review and staff interview, the facility failed to ensure to submit a written report of each incident specified in 22VAC40-73-70-A to the regional licensing office within seven days from the date of the incident that included actions to prevent recurrence of the incident, if applicable.

Evidence

Staff person 1 submitted an incident report to the licensing inspector (LI) on 05/29/2024 that it was reported to staff person 1 by staff person 2 that resident 1 has been physically abused by two current employees (staff persons 3 and 4).
During on-site inspection on 07/16/2024, the LI was informed by staff person 1 that staff person 3 had been terminated based on the findings of the facility’s investigation of the reported 05/29/2024 incident. The LI had not been made aware of this additional information until 07/16/2024.

Plan of correction

Written report completed and e-mailed to licensing on 8/23/2024 ED will copy Area ED on all correspondence with licensing so that Area ED can follow up with ED and ensure all reports are sent to licensing within the required time frame.

June 26, 2024Inspection2 violations

Inspection dates

06/26/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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

22VAC40-73-640-A

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

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.
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.
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.
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.

22VAC40-73-325-C

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

The uniform assessment instrument (UAI) for resident 1, dated 07/18/2023, indicates that the resident was assessed as assisted living level of care.
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

May 7, 2024Inspection1 violation

Inspection dates

05/07/2024

Areas reviewed

22VAC40-73 PERSONNEL

Comments

Type of inspection: Monitoring Inspection was conducted via phone on 05/07/2024 to verify evidence for the violation of the standard cited in this notice. 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

22VAC40-73-150-B-6

Based on collateral documentation and staff interview, the facility is currently being operated by an acting administrator for longer than 150 days.

Evidence

The licensing inspector (LI) was notified via email by staff person 1 on 10/04/2023 that the facility’s current administrator’s last day would be 10/15/2023 and that the facility was naming staff person 2 as the facility’s acting administrator effective 10/16/2023.
Staff person 2 received their acting assisted living facility administrator-in-training license from Collateral 1 effective 12/05/2023 with an expiration date of 05/03/2024.
During phone call with staff person 1 on 05/07/2024, staff person 1 verified to the LI that they are still the facility’s acting administrator.

Plan of correction

TerraBella Pheasant Ridge will have an acting administrator in place by 5/17/2024.

May 2, 2024Complaint survey3 violations

Inspection dates

05/02/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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

22VAC40-73-680-D

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

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.
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.
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

22VAC40-73-680-B

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

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.
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.
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

22VAC40-73-280-B

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

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).
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.
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

April 17, 2024Inspection0 violations

Inspection dates

04/17/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 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 self-reported incident was received by VDSS Division of Licensing on 04/05/2024 regarding allegations in the area(s) 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 did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 17, 2024Complaint survey1 violation

Inspection dates

04/17/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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

22VAC40-73-130-A

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

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.
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.
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.

March 14, 2024Inspection1 violation

Inspection dates

03/14/2024

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

22VAC40-73-680-D

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

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.
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.
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.

March 13, 2024Complaint survey0 violations

Inspection dates

03/13/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 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 complaint was received by VDSS Division of Licensing on 03/08/2024 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 did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 13, 2024Inspection0 violations

Inspection dates

03/13/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 22, 2024Complaint survey7 violations

Inspection dates

02/22/2024, 03/25/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 02/22/2024 9:00AM until 1:15PM and 03/25/2024 9:30AM until 11:30AM 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 02/14/2024 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 allegations of non-compliance with standard(s) or law, and violation(s) were 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. 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

22VAC40-73-650-F

Based on resident record review and staff interview, whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident’s return to the facility and the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.

Evidence

Resident 1 was sent to the emergency department on 07/02/2023 due to having a fall. Hospital documentation indicates on page 20 the following information: de-prescribe medications that are causing/contributing to falls, dry mouth, constipation: stop oxybutynin due to high risk with little benefit, reduce metoprolol tartrate from 150MG two times a day to 100MG two times a day due to the resident being orthostatic on this date (systolic blood pressure drops from 130-103 with standing and heart rate ranges from 50-65 at rest), reduce trazodone from 100MG every night to 50MG every night, transition off of anticholinergic paroxetine to more appropriate SSRI in the elderly (reduce paxil 40MG to 30MG for two weeks, then reduce paxil 30MG to 20MG for two weeks, then reduce paxil 20MG to 10MG for two weeks then stop paxil; initiate Zoloft 25MG daily the day after the last dose of paxil 10MG), monitor weights 3x week, increase to furosemide 40MG two times a day for three days if greater than three pound weight gain in a day or greater than five pound weight gain in a week, follow-up incidental renal mass (right kidney with outpatient renal ultrasound), dry mouth (dental caries, gingivitis; was requested for a referral to dentistry), continue physical and occupational therapy as already doing at the facility and continue to use walker. The record for resident 1 does not contain documentation that the resident’s primary physician was made aware of all medication orders or that any contact was made with the resident’s primary physician regarding the new orders. Interview with staff person 1 confirmed that this was accurate.
Resident 1 was in the hospital from 09/03/2023 through 09/04/2023. The after-visit summary for this hospitalization indicated for the resident to start taking Dorzolamide eye drops and to “ask how to take: acetaminophen 500MG (Tylenol)”. The record for resident 1 does not contain documentation that the resident’s primary physician was made aware of all medication orders or that any contact was made with the resident’s primary physician regarding the new orders. Interview with staff person 1 confirmed that this was accurate.

Plan of correction

When a resident has been hospitalized either prior to or upon return to community the RCC/MCD will fax primary MD and Pharmacy the hospital discharge paperwork noting any new orders or changed medications. RCC/MCD will attach fax confirmation sheet to discharge paperwork and initial and date and give to ED. ED will review, initial, and place in file folder in Nursing office to be filed. Nightshift RMA/Care Managers will file nightly. RCC/MCD will schedule all post hospital follow up and place on calendar and document in resident file.

22VAC40-73-680-D

Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 1 contains a signed physician’s order, dated 07/20/2023, for Advair (Fluticasone-Salmeterol 250-50) inhale one puff by mouth two times a day for COPD.
The August 2023 medication administration record (MAR) for the resident indicates that Fluticasone-Salmeterol 250-50 was being administered to the resident at 9:00AM and 5:00PM daily; however, the medication was not administered on the following dates/times: 08/12/2023 and 08/13/2023 at 9:00AM and on 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, and 08/14/2023 at 5:00PM due to “medication ordered awaiting pharmacy delivery”; 08/10/2023 at 9:00AM due to “medication ordered awaiting pharmacy delivery” and “NP wrote new prescription today” and on 08/11/2023 at 9:00AM due to “need a new script to fill – contacting primary care physician”.
The record for resident 1 contains a signed physician’s order, dated 09/04/2023, for Dorzolamide 2% eye drops apply one drop in the morning, one drop at noon, and one drop before bedtime.
The October 2023 MAR for the resident indicates that Dorzolamide 2% eye drops were being administered to the resident at 8:00AM, 12:00PM and 8:00PM daily; however, the eye drops were not administered on 10/30/2023 at 12:00PM and 10/31/2023 at 8:00AM and 12:00PM due to “pending delivery”. The November 2023 MAR for the resident indicates that Dorzolamide 2% eye drops are to be administered to the resident at 8:00AM, 12:00PM and 8:00PM daily; however, the eye drops were not administered on 11/01/2023 at 12:00PM (pending delivery), 11/02/2023 at 12:00PM (pending delivery), 11/03/2023 at 8:00AM (pending delivery) and 12:00PM (pending delivery), 11/04/2023 at 8:00AM (needs a new prescription), 12:00PM (needs new prescription) and 8:00PM (pending delivery) , 11/05/2023 at 8:00AM (needs new prescription. will call eye Doctor Monday) and 12:00PM (needs new prescription), 11/06/2023 at 8:00AM (waiting on new prescription), 12:00PM (waiting for new scrip), and 8:00PM (new script needed), 11/07/2023 12:00PM (waiting for new perscription [sic] to be faxed to pharmacy) and 8:00PM (notified MD that new script is needed) and 11/08/2023 at 8:00AM (other). The record for the resident contains a physician’s order, dated 11/06/2023 and signed by the physician on 11/09/2023, that the resident needs new script for Dorzolamide HCL 2% eye drops due to pharmacy request. The December 2023 MAR for the resident indicates that Dorzolamide 2% eye drops are to be administered to the resident at 8:00AM, 12:00PM and 8:00PM daily; however, the eye drops were not administered on 12/12/2023 at 8:00PM (pending delivery), 12/13/2023 at 8:00AM and 12:00PM (pending delivery), 12/14/2023 at 12:00PM (pending delivery) and 12/16/2023 8:00AM (pending delivery), 12:00PM (pending delivery – pharmacy stated delivered Thursday, not on cart or in the refrigerator) and 8:00PM (pending delivery).
The record for resident 1 contains documentation that the resident was seen by the physician on 11/20/2023 due to request of facility staff for the resident having complaints of cough and congestion. The record for resident 1 contains a signed physician’s order, dated 11/20/2023, for Augmentin 875/127mg one tablet by mouth every 12 hours for 7 days for sinusitis. The November 2023 medication administration record (MAR) for resident 1 does not contain documentation that the aforementioned medication was ever administered to the resident. Interview with staff person 1 confirmed that this is accurate and that the physician’s order was never faxed to the pharmacy.

Plan of correction

(2) 4 hour Med Tech. refresher courses have been scheduled 4/25/2024 and 5/7/2024. All RMA's will take 4 hour Med. Tech refresher course or will be pulled off of the med. cart until they have proof of taking course. ED or designee will re-educate RCC, MCD, and all RMA's on The Bin System RCC/MCD or designee will check bin folders each morning and follow up on any orders that are in the file from the previous day.

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall.

Evidence

The uniform assessment instrument (UAI) for resident 1, dated 03/27/2023, indicates that the resident was assessed as assisted living level of care.
The record for resident 1 contains documentation from the emergency department, dated 07/02/2023, that the resident was brought to the emergency department due to a fall.
The record for resident 1 contains a healthcare practitioner fax communication form, dated 11/14/2023 and signed by a physician on 11/16/2023, that the resident had a fall on 11/14/2023 and that the resident said she hit her back on the metal piece of the bed frame and had been having dizzy spells on this date.
The record for the resident does not include an updated fall risk rating regarding the 07/02/2023 fall or the 11/14/2023 fall. Interview with staff person 1 confirmed that this is accurate.

Plan of correction

The RCC/MCD or designee will perform a complete audit of all Resident charts to ensure an initial fall risk assessment has been completed and is in resident chart. A Fall risk assessment will be completed annually, with change in condition, and after a fall. Fall risk assessments will be logged on audit tool

22VAC40-73-70-A

Based on resident record review, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

Resident 1’s agreement with the facility was signed on 03/27/2023 and the resident’s physical move in date was 03/30/2023 per the facility’s “move in form” provided by staff person 1. The record for resident 1 contains hospital documentation indicating that the resident was moving into the facility on 03/30/2023, had a fall and went to the ER due to her hitting her head on the sidewalk and obtained a small laceration to her scalp.
Hospital documentation indicates that the resident was sent to the hospital on 07/02/2023 for the following: fall, injury of head, left hip pain and multiple falls. Also, the hospital documentation states that the resident has had recurrent falls while on blood thinner in the setting of dizziness and hyperpolypharamacy indicating several potentially inappropriate medications in the elderly.
The aforementioned incidents were not reported to the regional licensing office.

Plan of correction

All clinical staff will be re-educated by ED on what is considered a major incident. RCC/MCD will immediately notify the ED of any major incident. ED will send formal report of major incident to regional licensing office within 24 hours.

22VAC40-73-325-C

Evidence

The uniform assessment instrument (UAI) for resident 1, dated 03/27/2023, indicates that the resident was assessed as assisted living level of care.
The record for resident 1 contains emergency department documentation, dated 03/30/2023, that the resident presented to the emergency room due to a fall from standing position and an emergency department after visit summary, dated 06/15/2023, that the resident was in the emergency department due to a fall from standing.
The 03/30/2023 and 06/15/2023 fall risk assessments in the record for the resident do not contain documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls.
Interview with staff person 1 confirmed that this is accurate.

Plan of correction

RCC/MCD will discuss all falls during daily stand-up meeting. RCC/MCD will perform fall risk assessment and post fall investigation following all resident falls and log on fall audit tool. Copies of completed fall assessments and post fall investigation forms will be placed in resident file. RCC/MCD will update UAI/ISP due to falls and any new interventions.

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure that all resident records shall be kept current.

Evidence

Interview with staff person 1 revealed that the following physician progress notes, dated 03/31/2023, 04/04/2023, 04/24/2023, 05/01/2023, 05/03/2023, 06/12/2023, 06/15/2023, 06/22/2023, and 06/26/2023, had to be faxed to the facility on 03/07/2024 by the physician due to the aforementioned physician progress notes not being in the resident’s record or within the facility upon the licensing inspector’s request.
During resident 1’s record review, the LI noted that the resident’s record did not contain documentation of the resident’s 07/02/2023 emergency department visit. The LI requested and obtained the 07/02/2023 emergency department documentation since this document was not in the resident’s record. Interview with staff person 1 confirmed that the aforementioned emergency department visit documentation was not in the resident's record.

Plan of correction

ED will obtain a list of residents that are seen when house MD makes rounds. ED will have House MD fax progress notes within 24 hours to ED's attention. ED will compare progress notes to resident list, initial and date note and place in file folder in nursing office. Night shift clinical staff to file nightly. ED will use appointment calendar for all residents who follow up with outside MD and will call office to ensure office visit note is sent to community. ED will initial office note and file in file folder in Nursing office Clinical staff on night shift will file every night. If resident goes to ER, ED will ensure ER paperwork returns with resident or will call and request ER paperwork, initial and give to RCC/MCD to follow up any new medications/orders.

22VAC40-73-470-A

Based on resident record review and staff interview, the facility failed to ensure that, either directly or indirectly, the health care service needs of residents are met.

Evidence

The record for resident 1 contains an emergency department after visit summary, dated 06/15/2023, and a neurosurgery after visit summary, dated 07/18/2023, that contained documentation for the following scheduled visits for the resident: arterial lower extremity duplex unilateral with vascular surgery visit on 08/16/2023 at 12:00PM and coordinated hearing test with audiology 08/22/2023 at 2:00PM. Interview with staff person 1 revealed that the resident did not attend the two aforementioned appointments.
The record for resident 1 contains documentation from an ophthalmology visit, dated 07/27/2023, that the resident was to return to the same ophthalmology office in two months for a follow-up visit. Interview with staff person 1 revealed that the resident did not attend this follow-up appointment.
The record for resident 1 contains an after-visit summary from the hospital, dated 09/03/2023 and 09/04/2023, that contained documentation for the following scheduled visit: arterial upper extremity duplex unilateral with vascular surgery on 10/17/2023. Interview with staff person 1 revealed that the resident did not attend this appointment. The same after-visit summary also contained documentation on page 1 that the resident was to follow-up with an ophthalmologist appointment (outpatient) and included instructions and contact information for the resident to call and schedule after 8:00AM on 09/05/2023. The resident had been in the hospital on 09/03/2023 through 09/04/2023 due to eye pain. Interview with staff person 1 revealed that this appointment was not scheduled and the resident never went to this appointment.
The record for resident 1 contains a physician’s progress note, dated 10/16/2023, that the resident’s presenting problem is right shoulder pain; therefore, the physician ordered an x-ray of the resident’s right shoulder along with an orthopedic evaluation/consultation for the resident requesting Tylenol 500MG by mouth twice daily. The record for the resident also contains a signed order for the aforementioned x-ray and orthopedic evaluation/consultation dated 10/16/2023. Interview with staff person 1 revealed that the resident did not have an x-ray or an orthopedic evaluation/consultation.
The record for resident 1 contains a physician’s progress note, dated 11/20/2023, that the resident has complaints of broken teeth with dental pain and to obtain a dental consult as soon as possible along with a signed physician’s order, dated 11/20/2023, for a dental consult as soon as possible. Interview with staff person 1 revealed that the resident did not have a dental consult.
Staff person 1 was also unable to provide any documentation on why the resident did not attend any of the aforementioned appointments.

Plan of correction

RCC/MCD or designee will review all post hospital paperwork when resident returns to community, fax to Pharmacy, print fax confirmation sheet, and initial and date. Follow Bin system instructions. An appointment calendar will be kept in RCC and MCD workspace. RCC/MCD or designee will schedule any ordered appointments and plot on calendar and make notation of appointment in resident record. The RCC/MCD or designee will print off copy of weekly appointments and give to ED or designee on Friday for the following week. ED or designee will schedule transportation if needed.

February 13, 2024Complaint survey0 violations

Inspection dates

02/13/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 02/13/2024 9:00AM until 10:30AM 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 02/09/2024 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 did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 23, 2024Inspection8 violations

Inspection dates

01/23/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2024 8:16AM until 4:09PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, medication cart audit, and meals 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

22VAC40-73-930-D

Based on resident record review and facility documentation review, the facility failed to ensure to document rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds, for each resident with an inability to use the signaling device.

Evidence

The individualized service plan (ISP) for resident 9, dated 03/10/2023, and the ISP for resident 10, dated 03/27/2023, both indicate that residents 9 and 10 have an inability to use the signaling device and that both residents will have two-hour rounds to monitor for emergencies or other unanticipated needs.
The rounding logs reviewed for both residents 9 and 10 during on-site inspection contain numerous days during January 2024 that do not contain documentation of the staff person(s) who preformed rounds on residents 9 and 10.

Plan of correction

ED or designee will perform daily audits of 2 hour round sheets to ensure rounds are being completed by 2/5/24. ED or designee will perform 100% ISP audit of residents that have an inability to use the signaling device to ensure it is on the ISP by 2/17/2024

22VAC40-73-440-A

Based on resident record review and staff interview, all residents of assisted living facilities (ALF) shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110-30-F) which includes that the UAI shall be completed annually on all individuals residing in an ALF.

Evidence

During an on-site inspection on 1/23/2024, the record for resident 6 contained a UAI dated 12/22/2022.
During an interview with two Licensing Inspectors (LIs) and staff person 5, staff person 5 revealed the UAI, dated 12/22/2022, in the record for resident 6 is the most recent UAI completed for the resident.

Plan of correction

ED or designee will perform 100% chart audit for annual UAI dates on 2/29/24. Any UAI out of compliance will be completed immediately.

22VAC40-73-450-F

Based on resident record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months.

Evidence

During an on-site inspection on 1/23/2024, the record for resident 6 contained an ISP dated 12/22/2022.
During an interview with two Licensing Inspectors (LIs) and staff person 5, staff person 5 revealed the ISP, dated 12/22/2022, in the record for resident 6 is the most recent ISP completed for the resident.

Plan of correction

ED or designee will complete 100% chart audit of ISP’s to ensure they have been reviewed and updated at least every 12 months by 2/29/24. Any ISP’s out of compliance will be updated immediately.

22VAC40-73-640-A

Based on an audit of facility medication carts, staff interview and facility policy review, the facility failed to ensure the medication management plan (MMP) shall address procedures for administering medication which includes methods to prevent the use of outdated, damaged, or contaminated medications.

Evidence

During an audit of the memory care medication cart, two licensing inspectors (LI) observed an opened Novolog insulin pen in the top drawer for resident 11. Manufacturer’s instructions for Novolog indicate that once this insulin pen is opened it expires in 28 days. The Novolog insulin pen did not contain information of when the pen had been opened.
Interview with staff person 6 revealed that she was not the staff person who put the insulin pen in the medication cart and was unsure of when it had been opened and indicated that she had used the Novolog insulin pen on 01/23/2024 for resident 11 during the morning medication administration.
The MMP, dated 7/1/2021, provided by staff person 5 during on-site inspection as the facility’s current MMP, did not include a method to prevent the use of outdated, damaged, or contaminated medications.

Plan of correction

ED or designee will perform 100% med cart audit to ensure all bulk medications have open dates and/or expiration dates by 2/17/24. Any medications found to be out of compliance will be discarded immediately. New Medication Management plan put into place 2/1/24 and will be sent to licensing by 2/2/24.

22VAC40-73-450-C

Based on resident record review and staff interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission.

Evidence

During an on-site inspection on 01/23/2024, the record for resident 1 indicated the resident was admitted to the facility on 12/22/2023 and the record for resident 3 indicated the resident was admitted to the facility on 12/05/2023. The records for residents 1 and 3 did not contain a comprehensive ISP.
During an interview with two licensing inspectors (LIs) and staff person 5, staff person 5 revealed that a comprehensive ISP had not been completed for residents 1 and 3.

Plan of correction

ED or designee will perform 100% chart audit of all resident files to ensure the ISP has been completed within 30 days of admission by 2/29/24 Any ISP found missing will be completed immediately.

22VAC40-73-680-D

Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

Resident 3 was admitted to the facility on 12/05/2023.
The record for resident 3 includes an electronically signed progress note from Collateral 2, dated 12/07/2023, that Collateral 2 noted polypharmacy and is discontinuing the resident’s prescribed fish oil, multivitamin, vitamin C and Protonix. The record for the resident also includes a signed order, dated 12/07/2023, that contains the same information.
The December 2023 medication administration record (MAR) for resident 3 includes documentation that the resident was administered the aforementioned medications and that these medications were not discontinued per the signed physician’s order.
The January 2024 MAR for resident 3 includes documentation that the resident was administered fish oil, multivitamin, and vitamin C from 01/01/2024 through 01/23/2024 and Protonix was administered from 01/01/2024 through 01/11/2024.

Plan of correction

ED or designee will perform 100% MAR audit, Comparing MAR and Printed orders to ensure they match. By 2/29/24. ED or designee will in-service all clinical staff on New 4 bin order system by 2/17/24.

22VAC40-73-260-A

Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.

Evidence

The record for staff person 1 who is a direct care staff member, date of hire 11/15/2023, did not include evidence that this staff person has received certification in first aid. Interview with staff person 5 confirmed that staff person 1 does not have first aid certification.

Plan of correction

The Executive Director (ED) or designee will perform an audit of all employee files to ensure all staff have first by 2/17/2024. First aid and CPR class will be scheduled by 2/29/2024

22VAC40-73-950-E

Based on staff interview, the facility failed to ensure to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers and shall be documented by signing and dating.

Evidence

During on-site inspection on 01/23/2024, staff person 5 was unable to produce evidence that a semi-annual review of the facility’s emergency preparedness and response plan for all staff, residents, and volunteers had occurred.

Plan of correction

Director of Facility Ops or designee will conduct an Emergency preparedness and response in-service for all staff and residents by 2/29/24

October 23, 2023Complaint survey1 violation

Inspection dates

10/23/2023

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 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

22VAC40-73-200-C

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

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.
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.

October 2, 2023Complaint survey0 violations

Inspection dates

10/02/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 10/02/2023 09:45 to 12:00 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 09/05/2023 regarding allegations in the areas of: Resident Care and Related Services and Buildings and Grounds 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 standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 2, 2023Complaint survey0 violations

Inspection dates

10/02/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 10/02/2023 09:45 to 12:00 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 09/20/2023 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Ground 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 19, 2023Inspection0 violations

Inspection dates

05/19/2023

Areas reviewed

22VAC40-80 THE LICENSE22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

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: 05/19/2023 9:30AM until 10:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 16, 2023Inspection0 violations

Inspection dates

03/16/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 03/16/2023 10:15AM until 3:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 8, 2023Inspection16 violations

Inspection dates

02/08/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

To ensure that the facility had a thorough understanding of the standards, the licensing inspectors (LIs) had a discussion with the Administrator and the Director of Nursing regarding the following standard(s): 260-A

Comments

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 02/08/2023 8:50AM until 5:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: observed medication passes, activities, and noon-time meal. 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

22VAC40-73-1100-A

Based on resident record review, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval from the approving party.

Evidence

The record for resident 2 contained the document, Approval for Placement in Special Care Unit, which indicated that the resident’s guardian/legal representative and independent physician give approval for resident 2 to be placed in a special care unit; however, the form was not signed and dated by either party.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Director of Health and Wellness corrected resident #2’s Approval for Placement in a Special Care Unit form by obtaining written approval from the legal guardian on 2/9/23. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident Approval for Placement forms by 3/31/23. 3. The Director of Health and Wellness and/or designee will audit all new admission’s records to verify an appropriately completed Approval for Placement in a Special Care Unit form to ensure compliance. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 resident charts and their Approval for Placement in a Special Care Unit form for 3 months to ensure continued compliance.

22VAC40-73-450-D

Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP).

Evidence

The ISP for resident 2, dated 01/11/2023, states that this resident is receiving hospice services; however, the ISP does not indicate the types of services that hospice is providing.
The record for resident 7 contains the Hospice IDG Comprehensive Assessment and Plan of Care report which indicates that this resident has been receiving hospice services since 07/28/2022; however, the ISP for resident 7, dated 08/11/2022, does not indicate that this resident is receiving hospice services.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Director of Health and Wellness or designee will correct the ISP for resident #2 to reflect their current type and frequency of services provided by hospice. 2. Director of Health and Wellness or designee will correct the ISP for resident #7 to reflect that they are receiving hospice services, as well as to clarify the current type and frequency of services provided by hospice. 3. Director of Health and Wellness or designee will audit all resident ISPs for accuracy by 3/31/2023. 4. Director of Health and Wellness and/or designee will audit 10 ISPs per month for next 3 months to ensure compliance.

22VAC40-73-1110-A

Based on resident record review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be placed in the resident’s file.

Evidence

The records for resident 2 and resident 3 indicate that both residents reside in the facility’s safe, secure unit; however, neither record contained written determination and justification for appropriate placement in the special care unit by the licensee, administrator, or designee.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Administrator/Designee created a Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit and completed for Resident #2 and #3. The administrator completed new forms for all residents residing on the special care unit on 2/8/2023. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit by 2/28/23. 3. The Director of Health and Wellness and/or designee will audit all new admission’s records to verify an appropriately completed Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit to ensure compliance. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 resident charts and their Terrabella Pheasant Ridge form for written determination and justification for appropriate placement in the special care unit for 3 months to ensure continued compliance.

22VAC40-73-660-B

Based on observation, resident record review and staff interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.

Evidence

The uniform assessment instrument (UAI) for resident 11, dated 07/14/2022, indicates that the resident requires medications to be administered/monitored by a registered medication aide and/or licensed practical nurse. During on-site inspection, one licensing inspector (LI) and staff 6 noted that there was a bottle of Miralax in resident 11’s room. Resident 11 stated that she takes Miralax at least daily for constipation and that she administers it herself. The record for resident 11 did not contain a physician’s order that the resident can self-administer Miralax. Interview with staff 7 confirmed this was accurate.
The UAI for resident 8, dated 12/13/2022, indicates that the resident requires medications to be administered/monitored by a registered medication aide and/or licensed practical nurse. During on-site inspection, two LIs noted that there was a bottle of Extra Strength Excedrin on the resident’s table. Resident 8 stated that she self-administers this medication. The record for resident 8 did not contain a physician’s order that the resident can self-administered Excedrin. Interview with staff 7 confirmed this was accurate.

Plan of correction

22VAC40-80-120-A-1

Based on document review, observation and resident record review, the facility failed to operate within the terms of its license.

Evidence

The building evaluation, dated 04/25/2012, and the certificate of occupancy, dated 04/27/2012, for the facility indicates that the first floor of the facility, with exception to the facility’s safe, secure unit, is only permitted to house five or less non-ambulatory persons with grade level access and the facility’s second and third floors are for ambulatory persons only who do not require any assistance from anyone to evacuate the building in an emergency. The license issued to the facility, dated 09/21/2022 through 03/20/2023, indicates that floors two and three are ambulatory residents only, the safe, secure unit located on the first floor may have all non-ambulatory residents and the rest of the first floor is limited to five non-ambulatory residents. The aforementioned information was also confirmed by Collateral 1 on 02/13/2023.
The report of resident physical examination for resident 1, dated 01/10/2023, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. The UAI for the resident, signed by staff 6 and 7 on 01/05/2023, indicates that walking is not performed by the resident and interview with staff 7 on 02/08/2023 indicated that the resident is unable to climb stairs. The individualized service plan (ISP) for resident 1, dated 02/03/2023, indicates that the resident requires physical assistance to be escorted to the nearest exit to evacuate in the event of an emergency and that this is to be provided by activities and care staff. Resident 1 resides on the third floor of the facility.
The report of resident physical examination for resident 7, dated 04/20/2021, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. The ISP for resident 7, dated 08/11/2022, indicates that the resident requires verbal cues to safely evacuate in case of an emergency and that this is to be provided by direct care staff and that the resident can use the stairs in the case of an emergency with the supervision of staff. Resident 7 resides on the second floor of the facility.
The report of resident physical examination for resident 8, dated 12/12/2022, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. The uniform assessment instrument (UAI) for the resident, dated 12/12/2022, indicates that walking and stairclimbing is not performed by the resident. The ISP for the resident, dated 12/13/2022, indicates that the resident is to be provided physical assistance to be escorted to the nearest exit to evacuate in the event of an emergency and that this is to be provided by activities and care staff. During on-site inspection on 02/08/2023, it was noted by the licensing inspectors (LIs) during observation of the resident and resident interview that resident 8 is bed-bound and is unable to walk on her own. Resident 8 resides on the third floor of the facility.

Plan of correction

22VAC40-73-700-2

Based on observation during a tour of the building, the facility failed to post “No Smoking-Oxygen in Use” signs in rooms of the building where oxygen is in use.

Evidence

During on-site inspection, one licensing inspector (LI) observed that resident 7 was in her room receiving oxygen therapy through a concentrator; however, a “No Smoking-Oxygen in Use” sign was not posted in the room nor on the door to the room. Also, rooms 128 and 320 were noted to have oxygen in the rooms; however, there was no sign posted in the room or on the door to the room that oxygen is in use.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Director of Health and Wellness posted No smoking signs on all resident room that contained oxygen on the date of inspection. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident charts to ensure oxygen orders and appropriate signs are in place as appropriate by 3/31/23. 3. The Director of Health and Wellness and/or designee will audit all new admission’s records and rooms for oxygen orders and supplies upon admission. 4. Director of Health and Wellness or designee will perform an audit of all rooms designated to contain oxygen monthly for 3 months to ensure proper signage.

22VAC40-73-860-D

Based on observation during a tour of the building, the facility failed to ensure that any operable window shall be effectively screened.

Evidence

During on-site inspection, one licensing inspector observed that the window at the end of the hallway on the south end of the first floor had the ability to open; however, the window was not screened.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 2/8/2023 but received 2/17/2023.. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. During on-site inspection, one licensing inspector observed that the window at the end of the hallway on the south end of the first floor had the ability to open; however, the window was not screened. 2. Maintenance Director or designee will complete an audit of all windows and replace damaged/missing screens. Audit to be completed by 3/3/2023 and replacements ordered. Based on availability screens will be repaired or replaced by 3/31/23. 3. Audit will be completed monthly for 3 months.

22VAC40-73-440-D

Based on resident record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required.

Evidence

The UAI for resident 1, dated 01/06/2023, indicates that resident 1 requires assistance with toileting and stairclimbing; however, the type of assistance is not indicated on the UAI. Interview with staff 7 confirmed that resident 1 requires human help physical assistance with toileting and that the resident is unable to climb stairs. Also, the UAI for resident 1 indicates that the resident is disoriented some spheres, some of the time; however, the spheres affected are not indicated. Interview with staff 7 confirmed that the sphere affected is time.
The UAI for resident 10, dated 10/03/2022, indicates that resident 10 requires assistance with toileting and transferring; however, the type of assistance is not indicated on the UAI. Interview with staff 7 confirmed that resident 10 requires mechanical assistance only with toileting and transferring.

Plan of correction

22VAC40-73-680-K

Based on record review and observation, the facility failed to ensure that the use of PRN (as-needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed; licensed health care professionals administer PRN medication; or if medication aides administer PRN medication, the resident’s physician or other prescriber’s order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.

Evidence

The record for resident 10 contains physician’s orders, dated 01/10/2023, for the following PRN medications: acetaminophen 325 mg tablet “take 2 tablets [=650 mg] by mouth every 6 hours as needed for pain/fever > 100.4. max of 3gm/24-hr-all sources”; mi-acid liquid “take 10mls. by mouth every 4 hours as needed for heartburn”; ondansetron hcl 4 mg tablet “take 1 tablet by mouth every 6 hours as needed for nausea/vomiting”; tramadol hcl 50 mg “take 1 tablet by mouth every 6 hours as needed for pain”.
The individualized service plan (ISP) for resident 10, dated 10/03/2022, indicates that the resident resides in the facility’s memory care unit due to a diagnosis of dementia with a serious cognitive impairment and requires the assistance of a registered medication aide (RMA) or licensed practical nurse (LPN) to administer the resident’s medications.
Documentation on the January and February 2023 medication administration records (MARs) for resident 10 contain documentation that RMAs administered PRN medications to resident 10 on 01/13/2023, 01/14/2023, 02/05/2023, and 02/08/2023; however, the prescribed prn medications for resident 10 do not indicate what the RMAs should do if symptoms persist.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Director of Health and wellness and/or designee will complete the Documentation of physician’s or other prescriber’s oral order for PRN medication form for provider review and obtain signed orders detailing symptoms that indicate the use of the medication for all PRN medications for residents unable to determine necessity by 2/28/23. 2. The Director of Health and Wellness and or designee will perform an audit on all residents that are incapable of determining when a PRN medication is needed by 2/28/23. 3. The Director of Health and Wellness and/or designee will complete the Documentation of physician’s or other prescriber’s oral order for PRN medication form for provider review and obtain signed orders detailing symptoms that indicate the use of the medication for all PRN medications for residents unable to determine necessity by 3/31/23. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 charts of current residents unable to determine necessity of PRN medication for orders needing symptoms that indicate the use of the medication, for 3 months to maintain compliance.

22VAC40-73-680-D

Based on observation during medication administration, resident record review and resident and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

The record for resident 12 contains a uniform assessment instrument (UAI), updated on 12/22/2022 by staff 7, that the resident is no longer to self-administer medications and medications are to be administered by registered medication aides (RMAs) and/or licensed practical nurses (LPNs), a note by staff 7, dated 12/22/2022, that the resident is no longer able to self-administered medications, and a physician’s order, dated 12/22/2022, to discontinue the order for resident to self-administer medication and now medication staff will administer medications to resident 12.
During on-site inspection, one licensing inspector (LI) observed staff 8 administer resident 12’s medication. Resident 12 proceeded to take and swallow all the medications given to her by staff 8 except the Furosemide 20MG tablet. When the LI questioned resident 12 about why she wasn’t taking the tablet, resident 12 proceeded to inform staff 8 and the LI that she doesn’t like to take the whole Furosemide 20 MG tablet in the morning and that staff leave the pill with her. The resident stated that she cuts the pill in half herself with her pill cutter and she saves the other half of the tablet to take either later in the day or not at all. Resident 12 then went to her dresser and obtained two half tablets of Furosemide from previous days that she had not taken, and this was also observed by staff 8.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Staff # 8 contacted resident #12’s provider on 2/9/2023 to clarify Lasix 20mg 1 tab by mouth daily following two refusals of the medication as dispensed. On 2/10 Resident #12’s provider gave new orders for Lasix 10mg, 1 tab by mouth, twice daily for leg swelling. 2. Director of Health and Wellness or designee will conduct an Inservice on proper administration of medications per the 7 rights of medication administration by 3/31/23. 3. Director of Health and Wellness or designee will complete 3 random medication cart observations weekly for 3 months to ensure compliance.

22VAC40-73-450-H

Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.

Evidence

The ISP for resident 1, dated 02/03/2023, indicates that the resident is to receive round checks every two hours and will be checked on frequently for safety and toileting by care staff. Interview with staff 7 revealed that the facility does not have documentation that the rounds are being conducted by care staff for the resident.

Plan of correction

22VAC40-73-860-I

Based on observation during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area.

Evidence

At approximately 9:42AM during on-site inspection, one licensing inspector (LI) noted that the door to room 211 was unlocked and there was a spray bottle of McKesson dermal wound cleanser sitting on the kitchen table. The bottle contained a warning to keep out of the reach of children.
At approximately 10:50AM during on-site inspection, the resident in room 208 was leaving her room and two LIs noted a container of Zep disinfectant spray was located on the bathroom sink and a spray bottle of Comet all-purpose cleaner was located on the table to the left of the front door. Also, at approximately 11:02AM, two LIs noted that the door to room 241 was unlocked and there was a spray bottle of Comet all-purpose cleaner located on the kitchen counter to the left of the door and a container of Lysol disinfectant spray in the resident’s bedroom. The resident located in this room was noted to be bedbound.

Plan of correction

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was reviewed and updated for a resident after a fall.

Evidence

The record for resident 6 contained facility staff charting notes that the resident fell on 11/22/2022, 11/30/2022 and 12/04/2022; however, the TerraBella Pheasant Ridge fall risk assessment in the record for the resident was not updated to reflect the aforementioned falls. Interview with staff 7 confirmed this was accurate.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Director of Health and Wellness will correct the ISP for resident 6 by 2/28/23. 2. The Director of Health and Wellness and/or designee will correct the TerraBella Pheasant Ridge fall risk rating assessment in resident #6’s record by 2/28/23 3. Director of Health and Wellness or designee will perform an audit of all current resident’s fall risks by 3/31/23. 4. Director of Health and Wellness or designee will educate all RMA’s and Nurses. regarding fall risk ratings tool requirement by 3/31/23 5. Director of Health and Wellness or designee will complete an audit of fall risk ratings in 10 resident records monthly for 3 months to ensure continued compliance.

22VAC40-73-450-C

Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all identified needs.

Evidence

The record for the resident contained a physician’s order, dated 01/08/2023, that the resident is to be prepared and served a mechanical soft diet 3 diet; however, the ISP for resident 1, dated 02/03/2023, indicates that resident 1 is to receive a regular diet and does not include information regarding the aforementioned prescribed diet.
The ISP for resident 4, dated 10/11/2022, that resident 4 requires no assistance with stairclimbing and also that the resident requires mechanical and human physical assistance with stairclimbing. Interview with staff 7 confirmed that the resident does require assistance with stairclimbing.
The ISP for resident 7, dated 08/11/2022, indicates that resident 7 does not require any assistance when performing stairclimbing if there is an emergency; however, on the date of inspection, resident 7 was observed to be confined to a bed and would require assistance for stairclimbing in the event of an emergency.

Plan of correction

22VAC40-73-1090-A

Based on resident record review, the facility failed to ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

The Assessment of Serious Cognitive Impairment form for resident 10, dated 07/20/2021, indicates that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia; however, the form also indicates that the resident is not unable to recognize danger or protect his/her own safety and welfare.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/23 but received 02/17/23. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Director of Health and Wellness and/or designee will have resident #10’s practitioner complete a new Assessment of Serious Cognitive Impairment to reflect his correct level of functioning by 2/28/23. 2. The Director of Health and Wellness and/or designee will conduct an audit of all resident Assessment of Serious cognitive impairment forms and correct with the resident’s practitioner by 3/31/23. 3. The Director of Health and Wellness and/or designee will audit all new admission’s records to verify an appropriately completed assessment of serious cognitive impairment to ensure compliance. 4. Director of Health and Wellness or designee will perform a monthly audit of 10 resident charts and their Assessment of Serious cognitive impairment for 3 months to ensure continued compliance.

22VAC40-73-860-G

Based on observation during a tour of the building, the facility failed to ensure hot water taps available to residents were maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit.

Evidence

During on-site inspection, one licensing inspector (LI) measured the following bathroom sink water temperatures in the following occupied rooms: Room 127 – 94.1 degrees Fahrenheit, Room 124 -104 degrees Fahrenheit and Room 217- 91.3 degrees Fahrenheit.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 02/08/2023 but received 02/17/2023. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. During on-site inspection, one licensing inspector (LI) measured the following bathroom sink water temperatures in the following occupied rooms: Room 127 – 94.1 degrees Fahrenheit, Room 124 -104 degrees Fahrenheit and Room 217- 91.3 degrees Fahrenheit. 2. Circulation pump malfunctioned during inspection. Was repair by Valley Boiler the next day. Water Temps corrected with Pump install. 3. Maintenance Director will audit Water Temperatures weekly ongoing.

February 8, 2023Complaint survey0 violations

Inspection dates

02/08/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 02/08/2023 9:00AM until 5:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 12/07/2022, 01/03/2023, 02/01/2023 and 02/06/2023 regarding allegations in the areas of: personnel, staffing and supervision, admission, retention and discharge of residents, resident care and related services, buildings and grounds, and additional requirements for residents with cognitive impairments. 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 30, 2022Inspection14 violations

Inspection dates

11/30/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

To ensure that the facility had a thorough understanding of the standards, the licensing inspectors and the administrator and the director of nursing had a discussion regarding standards 390-A, 1110-A and 550-F.

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 11/30/2022 9:05AM through 4:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: audit of medication carts in the assisted living section and safe, secure unit 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

22VAC40-73-410-A

Based on resident record review and staff interview, the facility failed to ensure an acknowledgment was signed and dated that an orientation for new residents and their legal representatives including emergency response procedures, mealtimes, and use of the call system was provided upon admission.

Evidence

The records for resident 1 and 2, admitted 09/21/2022, and resident 5, admitted 10/19/2022, lacked documentation that both residents and their legal representatives received orientation. Interview with staff 3 confirmed this was accurate.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective 1. Executive Director, Sales Director or Designee will develop and implement resident orientation into contract signing by 1/31/2023. 2. Sales Director or designee will complete Resident Orientation with Resident #5 by 12/31/2023 and place documentation in resident file. 3. Business Office Manager or designee will audit all resident files for resident orientation. 4. Business Office Manager or designee will give all residents admitted from 9/21/2022 forward the resident orientation information and place documentation in resident file. Complete 1/31/23 5. Executive Director will educate Business Office Manager and Sales Director on the DSS Standard requirement for Resident Orientation. Complete 12/31/22 6. Business Office Manager or designee will review each resident file at time of admission for compliance. An audit of all residents admitted from 9/21/2022 to current day will be completed.by 1/31/23

22VAC40-73-1040-B

Based on observation during a tour of the safe, secure unit, the facility failed to ensure that there were protective devices on a window in a common area accessible to residents with serious cognitive impairments to prevent the window from being opened wide enough for a resident to crawl through.

Evidence

At approximately 9:34 AM, one licensing inspector (LI) and staff 1 observed that the window on the far-right side of the dining room in the safe, secure unit did not have protective devices, and as a result, the LI was able to open the window far enough to crawl through.

Plan of correction

22VAC40-90-40-B

Based on staff record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.

Evidence

The record for staff 2, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 11/10/2022. The record for staff 9, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 12/07/2020. The record for staff 11, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 05/22/2022. The record for staff 18, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 12/21/2021. The record for staff 22, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 12/05/2016. The record for staff 26, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 09/29/2021. The record for staff 27, date of hire 09/21/2022, contained the results of a criminal record report in the record which was dated 06/11/2020.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. • The Executive Director or designee will provide education for Business Office Manager on Criminal History Records and Virginia regulations to be completed by 1/31/2022. • The Business Office Manager or Designee will audit all current staff records for Criminal History Records to be completed by 1/31/23. • New Criminal History Records will be run for anyone with a date prior to 9/21/22. • To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records and once a month for three months Complete 3/30/23.

22VAC40-73-310-B

Based on resident record review and staff interview, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the potential resident and his legal representative was conducted.

Evidence

The records for resident 4, admitted 10/29/2022, and resident 5, admitted 10/19/2022, lacked evidence of a documented interview between the administrator or a designee responsible for admission and retention decisions and the aforementioned residents and their legal representatives. Interview with staff 3 confirmed this was accurate.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Executive Director or Designee will create an Admissions Interview form and put into place for all new admissions. Complete by 1/31/23. 2. Executive Director or Designee will provide education to the Marketing director on completing Admissions Interview prior to resident admission by 1/31/20223. 3. Unable to retroactively correct date of Admissions Interview for resident number four. Admission Interview document will be completed for each resident admitted since 9/1/2022 by Marketing Director/ Designee. Completion by 1/31/2023.

22VAC40-73-320-A

Based on resident record review and staff interview, the facility failed to ensure the physical examination required within the 30 day preceding admission for a resident contained all the required components.

Evidence

The report of resident physical examination for resident 4, dated 10/28/2022, lacked the following required information: if the resident has gastric tubes, if the resident presents imminent physical threat or danger to self or others and/or if the resident requires continuous licensed nursing care. Interview with staff 3 confirmed that the facility did not have this information available at the facility during on-site inspection.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Director of Health and Wellness will obtain the documentation needed for resident #4 by 12/31/2022. 2. Director of Health and Wellness or designee will audit all new admissions for required components since licensing on 9/21/22 to ensure compliance. Complete 1/22/2023 3. Director of Health and wellness or designee will review history and physical forms prior to admission to ensure required documentation is complete. Immediate 4. Director of Health and wellness or designee will audit 10 resident History and Physical forms per month for 3 months to maintain compliance. Complete 3/30/23

22VAC40-73-870-A

Based on observation during a tour of the building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.

Evidence

While performing a walk-through of the memory care unit at 9:24 AM, one licensing inspector (LI) and staff 1 observed that the flooring at the threshold to room 177 was missing which created a gap in the flooring of the doorway.
One LI and staff 1 made the following observations in the memory care unit: dark scuffs across the lower portion of walls in the hallways and on the front of resident room doors; and the baseboard paint across from room 168 was chipped.
At approximately 10:00 AM, one LI observed that the walls throughout the dining room in the assisted living area had long scuffs and areas of dripping stains on the wall on the right side of the dining room.

Plan of correction

The following is the Plan of Correction for TerraBella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Rubber Threshold at Doorway of RM 177 was cleaned and glued back in place on 11/30/22. Immediate Correction 2. Executive Director or designee will provide education for Maintenance Manager and Maintenance Technician on Maintenance of interior to be kept in good repair by 1/31/2022. 3. Removal of wallpaper, new paint for all hallways and trim thru out Memory Care by 1/31/2023. RM 168 baseboard will be repaired and painted. Contractor scheduled to start work on 12/13/2023. 4. Maintenance Director or designee will touch up scuffs and paint in Assisted Living Dining room by 1/31/2023. 5. To assist with ongoing compliance, the Maintenance Director or Designee will conduct visual inspection of all public areas to ensure building is maintained in good repair once a month for three months.

22VAC40-73-250-D

Based on staff record review and staff interview, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility prior to coming into contact with residents submitted the results of a tuberculosis (TB) risk assessment.

Evidence

The record for staff 2, date of hire 11/14/2022, did not contain the results of a TB risk assessment. Interview with staff 3 confirmed this was accurate.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Business Office Manager will have a Tuberculosis Screening completed for staff #2 by 12/31/2022. 2. The Executive Director will provide education for Business Office Manager on staff record, initial and annual tuberculosis screenings, and Virginia regulations to be completed by 1/31/2023. 3. The Business Office Manager or Designee will audit all current staff records for initial tuberculosis screening to be completed by 1/31/2023. 4. To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff record for initial tuberculosis screening once a month for three months. Complete by 3/30/23

22VAC40-73-640-A

Based on observation during medication cart audits and staff interview, the facility failed to ensure the medication management policy was implemented.

Evidence

The Insulin Glargine insulin pen that was located on the medication cart for resident 6 did not contain the date in which staff opened the insulin pen for the resident, this was also observed by staff 4 and 7. During interview with staff 4, even though it is not stated in the facility’s medication management plan provided during on-site inspection, staff 4 stated that staff are to write open dates on medications that have expiration dates once they are opened.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Director of Health and Wellness or Designee will complete Medication Cart Audit on each medication cart by 1/31/2023. 2. DHW or Designee will provide education for nurses and RMAs on reviewing medications expiration dates and documenting date medication is opened on label. Completed by 1/31/22/2023. 3. To assist with on-going compliance; Director of Health and Wellness or Designee will conduct weekly med cart audits. Ongoing to maintain compliance

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to review and update the fall risk rating for a resident after the resident had fallen.

Evidence

The uniform assessment instrument (UAI) for resident 5, dated 10/06/2022, indicated that the resident is assisted living level of care. Doctor’s progress notes in the record for resident 5, dated 11/01/2022; 11/14/2022 and 11/22/2022, all indicated that the doctor was visiting the resident due to falls; three in total; however, the most recent fall risk rating in the record for the resident was dated 10/19/2022. Interview with staff 4 confirmed that the fall risk rating for the resident has not been reviewed and updated to reflect the past three falls.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Director of Health and Wellness or designee will correct the ISP for resident 5 complete by 12/30/2022. 2. The Executive Director (ED) or designee will provide education for the Health and Wellness Director and/or designee on fall risk ratings by 1/31/2023. 3. The Health and Wellness Director or designee will perform an audit of all current residents' fall risk ratings. Completed by 1/31/2023. 4. To assist with ongoing compliance, the Health and Wellness Director or designee will randomly audit current residents' fall risk ratings once a month for three months.

22VAC40-73-860-I

Based on observation during a tour of the safe, secure unit, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area.

Evidence

At approximately 9:30 AM, one licensing inspector (LI) and staff 1 noted that the door to the housekeeping closet was unlocked. The LI and staff 1 observed the following cleaning supplies on shelves within the housekeeping closet: Windex Multi-Surface Disinfectant Cleaner, Swiffer Wet Jet cleaning liquid, ECOLAB Miracle Spotter spray, D-STROY morning fresh spray, Monogram Disinfectant Bleach, Neutral Disinfectant Cleaner, as well as ECOLAB Disinfecting Acid Bathroom Cleaner and Peroxide Multi-Surface Cleaner and Disinfectant dispensers on the wall.

Plan of correction

22VAC40-90-30-B

Based on staff record review, the facility failed to ensure that the sworn disclosure statement was completed for all applicants for employment.

Evidence

Staff 6 through 28, all with a date of hire of 09/21/2022, contained a sworn disclosure statement that was either not completed for the new licensee which was established on 09/21/2022 or was completed after employee with the new licensee.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. • The Executive Director/designee will provide education for Business Office Manager on sworn disclosure statements and Virginia Regulations. Complete by 1/31/2023. • The Business Office Manager or Designee will audit all current staff records for sworn disclosure statements. Complete 1/31/23. • Business Office Manager/ Designee to have New Sworn Disclosure Statements completed for all staff as required for licensing on 9/21/22. Complete by 1/31/23 • Business Office Manager or Designee will audit all new staff records for sworn disclosure statements monthly for compliance.Ongoing

22VAC40-73-350-B

Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.

Evidence

The records for resident 4, admitted 10/29/2022, and resident 5, admitted 10/19/2022, did not contain documentation that a registered sex offender search was conducted for either resident. Interview with staff 3 confirmed this was accurate.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Executive Director, Business Office Manager or Designee will ascertain sex offender screening and results for resident 4 and resident 5 are completed by 1/31/2023. 2. The Executive Director or designee will provide education for Business Office Manager and Sales Director on resident sex offender screening and obtaining results prior to admission per Virginia regulations. Complete by 1/31/2023. 3. The Business Office Manager or Designee will perform an audit of current resident records for sex offender screening and results. Complete by 1/31/2023. 4. Business Office Manager or Designee will audit all new resident records for sex offender screening and results monthly for 3 months to maintain compliance

22VAC40-73-120-A

Based on staff record review and staff interview, the facility failed to ensure a staff person received the required orientation and training in standards 22VAC40-73-120-B and 22VAC40-73-120-C within the first seven working days of employment.

Evidence

Interview with staff 3 confirmed that staff 2, date of hire 11/14/2022, has been working on the floor and staff 3 confirmed that staff 2 has not received the required orientation and training as required in standards 22VAC40-73-120-B and 22VAC40-73-120-C.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. The Executive Director or designee will provide education for Business Office Manager on maintaining Record of Initial staff training as per Virginia regulations to be completed by 1/31/2023. 2. The Business Office Manager or Designee will complete audit of all current staff records for initial training completion of newly hired employees. Completed by 1/31/2023. 3. The Executive Director, Business Office Manager, or Designee will provide Initial staff training for any active associate that hasn’t completed training from 9/21/22 licensing date. 4. To assist with ongoing compliance, the Business Office Manager or Designee will audit each staff record for initial training compliance. To be completed monthly x 3 months then quarterly thereafter

22VAC40-73-50-A

Based on resident record review, the facility failed to ensure that the disclosure statement contained all required components.

Evidence

The record for resident 1, admitted 09/21/2022, contained a disclosure statement that did not include information on whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
The record for resident 2, admitted 09/21/2022, contained a disclosure statement that was not updated to include the new facility name and licensee information.

Plan of correction

The following is the Plan of Correction for Terra Bella Pheasant Ridge Senior Living regarding the Statement of Deficiencies date 11/30/2022 but received 12/5/20222. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 1. Unable to retroactively correct date of Written Disclosure for residents. ED/Designee will have Written Disclosure updated in all resident files by 1/31/2023. 2. The Executive Director will provide education for the Sales Manager, Business Office Manager or designee on regulations and completion of the Written Disclosure by 1/31/2023. 3. For on-going compliance, the Executive Director or Designee will audit 10% of resident records for Written Disclosure monthly for 3 months.

August 26, 2022Inspection1 violation

Inspection dates

08/26/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

Facility management was reminded that when the new license was issued, they would need the new company to hire the staff, including new background checks and orientation, and to have new contracts (resident agreements) signed.

Comments

Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/26/2022 9:40 am to 3:15 pm, with file review completed off site. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 9 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations

22VAC40-73-870-A

Based on observation, the facility failed to have the interior and exterior maintained in good condition.

Evidence

There was a broken switchplate with a piece missing in the lower level hallway near the laundry room.
Wallpaper was peeling in several places in the hallways of the memory care section.
Outside at the kitchen exit door, the door frame had some wood damage.

Plan of correction

Broken switch plate replaced with new on 8/26/2022 ¿ The Maintenance Director or Designee will obtain 2 quotes to remove wallpaper in Memory Care and Paint by 9-16-22. Wallpaper peeling in Memory care has been glued back in place by Maintenance Director. Completion of wallpaper removal or repair by 11/30/2022 or scheduled based on availability of contractor and materials. ¿ The Maintenance Director or Designee will obtain quote to repair or replace damaged wood siding area by 9-16-22. Completion of repairs by 11/30/2022 or scheduled based on availability of contractor and materials.