1 Inspection Summary
Inspection Reports Summary
Covers 52 inspections · Aug 2022 – May 2026Visit Reason
This report covers 52 inspections of TerraBella Pheasant Ridge from August 26, 2022 to May 26, 2026 by the Virginia Department of Social Services.
Complaint Details
Multiple complaint surveys were conducted, investigating allegations primarily in the areas of resident care and related services, personnel, buildings and grounds, and additional requirements for residents with serious cognitive impairments. Some complaints were substantiated resulting in violations, while others were not supported by evidence.
Findings
Across that history VDSS cited 128 violations under 64 distinct standards. 33 of 52 visits ended with violations and 19 with none. 26 inspections were prompted by a complaint.
Violations (55)
22VAC40-73-560-E: Resident records not kept current or retained at facility.
22VAC40-73-450-F: ISPs not reviewed and updated at least annually or as needed.
22VAC40-73-450-E: ISPs not signed and dated by licensee or resident/legal representative.
22VAC40-73-440-D: Private pay UAIs not completed as required.
22VAC40-73-870-A: Interior of buildings not maintained in good repair and clean.
22VAC40-73-640-A: Medication management plan not implemented for controlled substance counts.
22VAC40-73-1090-A: Assessment by independent physician for serious cognitive impairment not completed prior to admission.
22VAC40-73-680-E: Medical procedures not provided or documented as ordered by physician.
22VAC40-73-680-I: Resident MARs missing required documentation of staff initials.
22VAC40-73-470-A: Health care service needs of residents not met.
22VAC40-73-70-A: Major incidents not reported to regional licensing office within 24 hours.
22VAC40-73-70-C: Written incident reports not submitted to regional office within 7 days.
22VAC40-73-680-D: Medications not administered according to physician's instructions.
22VAC40-73-110-1: Staff not considerate and respectful of resident rights and dignity.
22VAC40-73-870-B: Buildings not well-ventilated and free from foul odors.
22VAC40-73-740-D: No written policy for missing resident possessions and investigations.
22VAC40-73-870-E: Furnishings and equipment not kept clean and in good repair.
22VAC40-73-640-A: Medication refills not timely to avoid missed dosages.
22VAC40-73-460-H: Personal care and bathing assistance not provided as needed.
22VAC40-73-660-B: Resident allowed to keep medications without physician order or UAI approval.
22VAC40-73-450-F: ISPs not updated for significant change of condition.
22VAC40-73-450-F: Comprehensive ISP not reviewed and updated at least annually or as needed.
22VAC40-73-450-E: ISP not signed and dated by resident or legal representative.
22VAC40-73-460-H: Personal assistance and care including bathing not provided as needed.
22VAC40-73-470-A: Health care service needs of residents not met.
22VAC40-73-560-E: Resident records not kept current and retained at facility.
22VAC40-73-450-F: ISPs not reviewed and updated as needed for significant change.
22VAC40-73-680-I: MAR missing date, time, and initials of staff administering medications.
22VAC40-73-450-F: ISPs not reviewed and updated at least annually or as needed.
22VAC40-73-680-D: Medications not administered according to physician's instructions.
22VAC40-73-680-I: MAR missing name, signature, and initials of staff administering medications.
22VAC40-73-70-A: Major incidents not reported to regional licensing office within 24 hours.
22VAC40-73-70-A: Major incidents not reported to regional licensing office within 24 hours.
22VAC40-73-70-C: Written incident reports not submitted to regional office within 7 days.
22VAC40-73-680-D: Medications not administered according to physician's instructions.
22VAC40-73-660-B: Resident allowed to keep medications without physician order or UAI approval.
22VAC40-73-660-B: Resident allowed to keep medications without physician order or UAI approval.
22VAC40-73-660-B: Resident allowed to keep medications without physician order or UAI approval.
22VAC40-73-450-F: ISPs not reviewed and updated at least annually or as needed.
22VAC40-73-660-B: Resident allowed to keep medications without physician order or UAI approval.
22VAC40-73-660-B: Resident allowed to keep medications without physician order or UAI approval.
22VAC40-73-450-F: ISPs not reviewed and updated at least annually or as needed.
22VAC40-73-680-D: Medications not administered according to physician's instructions.
22VAC40-73-450-F: ISPs not reviewed and updated at least annually or as needed.
22VAC40-73-450-E: ISPs not signed and dated by licensee or resident/legal representative.
22VAC40-73-440-D: Private pay UAIs not completed as required.
22VAC40-73-870-A: Interior of buildings not maintained in good repair and clean.
22VAC40-73-640-A: Medication management plan not implemented for controlled substance counts.
22VAC40-73-1090-A: Assessment by independent physician for serious cognitive impairment not completed prior to admission.
22VAC40-73-680-E: Medical procedures not provided or documented as ordered by physician.
22VAC40-73-680-I: Resident MARs missing required documentation of staff initials.
22VAC40-73-470-A: Health care service needs of residents not met.
22VAC40-73-70-A: Major incidents not reported to regional licensing office within 24 hours.
22VAC40-73-70-C: Written incident reports not submitted to regional office within 7 days.
22VAC40-73-680-D: Medications not administered according to physician's instructions.
Report Facts
Violations cited: 128
Distinct standards: 64
Inspections on page: 52
Inspections with violations: 33
Complaint visits: 26
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