Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-09-29 regarding allegations in the area of buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint investigation related to buildings and grounds; allegations were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-09-23 regarding allegations in the area of buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings were reviewed in an exit meeting and will be posted publicly.
Complaint Details
Complaint related to buildings and grounds; the allegations were not substantiated based on the investigation.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Aug 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-08-12 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Complaint Details
Complaint received on 2025-08-12 regarding additional requirements for facilities caring for adults with serious cognitive impairments; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Aug 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 08/13/2025 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Complaint Details
Complaint related to additional requirements for facilities that care for adults with serious cognitive impairments; allegations were not substantiated.
Report Facts
Number of residents present: 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
Inspection Report
Complaint Investigation
Deficiencies: 6
Aug 13, 2025
Visit Reason
The inspection was conducted due to a complaint received by VDSS Division of Licensing on 2025-07-24 regarding allegations in the areas of resident care and related services, resident accommodations and related provisions, and buildings and grounds.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued. Deficiencies included failure to provide adequate personal care such as bathing, failure to implement medication management plans to avoid missed dosages, incomplete medication administration records, lack of written policy for missing resident belongings, and issues with facility cleanliness and odor.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with applicable standards and laws.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure personal assistance and care are provided as necessary, including bathing at least twice a week or more often if needed. |
| Facility failed to implement medication management plan to ensure timely medication refills and avoid missed dosages. |
| Medication administration record did not include date, time given, and initials of staff administering medications. |
| Facility failed to develop and implement a written policy regarding procedures when resident's clothing or personal possessions are reported missing. |
| Facility failed to ensure all buildings are well-ventilated and free from foul, stale, and musty odors. |
| Facility failed to ensure furnishings, fixtures, and equipment are kept clean and in good repair, including a missing shower drain cover and soiled resident chair. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Dates resident received showers: 12
Missed medication doses: 4
Inspection Report
Monitoring
Deficiencies: 1
Aug 13, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-08-06 regarding personnel allegations.
Findings
The investigation supported the self-report of non-compliance related to staff failing to be considerate and respectful of resident rights, dignity, and sensitivities. Two staff members were suspended and subsequently terminated due to violations of resident rights.
Deficiencies (1)
| Description |
|---|
| 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. |
Report Facts
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Jun 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-18 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint related to resident care and related services; investigation did not substantiate the allegations.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 4
Jun 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 06/24/2025 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection. These included failures in compliance with facility policies, individualized service plan adherence, meeting health care service needs, and maintaining current resident records.
Complaint Details
The complaint was related to resident care and related services. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Failure to ensure compliance with the facility's own policies and procedures related to alert charting for residents on antibiotic therapy. |
| Failure to ensure that care and services specified in the individualized service plan (ISP) were provided, specifically incomplete 2-hour rounding logs. |
| Failure to ensure that the health care service needs of residents are met, including lack of documentation for scheduled medical appointments. |
| Failure to ensure all resident records were kept current and retained at the facility, including missing home health documentation. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 4
Jun 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-04-12 regarding allegations related to resident care and related services at TerraBella Pheasant Ridge.
Findings
The investigation supported the allegations of non-compliance with several standards, including failure to ensure individualized service plans were properly signed and updated, failure to provide necessary personal assistance with bathing, and failure to maintain cleanliness and good repair of furnishings and equipment. Violations were issued and plans of correction were required.
Complaint Details
The complaint investigation substantiated violations related to resident care, including inadequate individualized service plans and insufficient personal care assistance. The complaint was received on 2025-04-12 and the inspection was conducted on 2025-06-02.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or legal representative. |
| Facility failed to ensure the comprehensive individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for significant changes. |
| Facility failed to ensure personal assistance and care were provided as necessary, including assistance with bathing at least twice a week or more often if needed. |
| Facility failed to ensure all furnishings, fixtures, and equipment, including toilets, were kept clean and in good repair and condition. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Number of resident interviews conducted: 1
Dates of shower assistance: 7
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Jun 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-28 regarding allegations in the area of resident care and related services.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance related to resident care and related services. Violations were found regarding the completion and accuracy of the uniform assessment instrument (UAI) and failure to ensure residents' health care service needs were met.
Complaint Details
The complaint investigation was substantiated in part, with some allegations supported by evidence and resulting in a violation notice. The complaint related specifically to resident care and related services.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the uniform assessment instrument (UAI) was completed prior to admission, at least annually, and whenever there was a significant change in the resident's condition. The UAI for resident 1 was inaccurate regarding medication administration and mobility needs. |
| The facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met, as evidenced by unclear urinalysis testing and results for resident 1. |
Report Facts
Number of residents present: 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
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Jun 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-03-28 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding failure to ensure the comprehensive individualized service plan (ISP) was reviewed and updated at least annually and as needed for significant changes in a resident's condition.
Complaint Details
Complaint was received on 2025-03-28 regarding allegations in resident care and related services. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for significant change of a resident's condition. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 1
Number of staff interviews conducted: 8
Inspection Report
Monitoring
Census: 71
Deficiencies: 1
Jun 2, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services regulations.
Findings
The inspection found non-compliance with applicable standards related to medication self-administration, specifically the facility failed to ensure a resident was permitted to keep his own medication in an out-of-sight place in his room despite the resident being capable of self-administering medication according to the uniform assessment instrument.
Deficiencies (1)
| Description |
|---|
| 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 indicated capability of self-administration. |
Report Facts
Number of residents present: 71
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
Inspection Report
Monitoring
Deficiencies: 0
Mar 17, 2025
Visit Reason
The inspection was a monitoring visit conducted on March 17, 2025, to review personnel, resident care and related services, and criminal history record report compliance.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit. The findings will be posted publicly and a copy is required to be posted at the facility.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 5
Mar 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-14 regarding allegations in the area of resident care and related services.
Findings
The investigation found multiple violations related to individualized service plans, general responsibility for resident health and safety, health care service needs, medication orders after hospitalization, and medication storage. Violations were substantiated and corrective plans were required.
Complaint Details
The complaint was substantiated with violations issued related to resident care and related services. The investigation included resident record reviews, resident and staff interviews, and review of hospital and physician documentation.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan included a description of identified needs and date identified based on required assessments. |
| Facility failed to assume general responsibility for the health, safety, and well-being of the resident. |
| Facility failed to ensure that the health care service needs of residents are met. |
| Facility failed to obtain new orders for all medications and treatments prior to or at the time of the resident's return from hospital and failed to document contact with the primary physician regarding new orders. |
| 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 indicated capability of self-administering medication. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Number of resident interviews conducted: 1
Date to be corrected: Apr 11, 2025
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Feb 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-06 regarding allegations in administration and administrative services and resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within five business days.
Complaint Details
A complaint was received on 2025-02-06 alleging issues in administration and resident care. The evidence gathered did not substantiate the allegations.
Report Facts
Number of residents present: 70
Number of resident interviews: 5
Number of staff interviews: 3
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-20 regarding allegations in the areas of personnel and resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified concerning the facility's failure to implement its medication management plan to ensure timely medication administration.
Complaint Details
The complaint was not substantiated based on the evidence gathered during the investigation.
Deficiencies (1)
| Description |
|---|
| The facility failed to implement its medication management plan to ensure that each resident's prescription medications ordered were filled in a timely manner to avoid missed dosages. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 70
Deficiencies: 14
Jan 14, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations related to resident assessments, staff certifications, medication management, resident safety, and documentation. The facility was found non-compliant with several standards, and violation notices were issued with plans of correction required.
Deficiencies (14)
| Description |
|---|
| Failed to ensure resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission. |
| Failed to obtain written approval prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to ensure harmful materials were inaccessible to residents except under staff supervision. |
| Failed to retain written acknowledgment of disclosure receipt in resident records. |
| Failed to ensure direct care staff maintained current certification in first aid. |
| Failed to ensure direct care staff had refresher training in dealing with aggressive or dangerously agitated residents annually or as needed. |
| Failed to obtain physical examination with all required information within 30 days preceding admission. |
| Failed to review and update fall risk rating after resident falls. |
| Failed to communicate and establish coordinated plan of care with hospice organization including services on individualized service plan. |
| Failed to provide freedom of movement by locking residents out or inside their rooms in the safe, secure unit. |
| Failed to implement medication management plan ensuring accurate counts of controlled substances during staff changes. |
| Failed to administer medications in accordance with physician's or prescriber's instructions. |
| Failed to ensure Do Not Resuscitate (DNR) orders met all requirements for withholding CPR. |
| Failed to obtain criminal history record report on or prior to 30th day of employment for staff. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 5
Dec 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-02 regarding allegations related to admission, retention and discharge of residents, and resident care and related services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in resident care and related services. Multiple violations were cited related to fall risk rating updates, uniform assessment instrument completion, individualized service plan updates, personal care assistance, and resident record maintenance.
Complaint Details
The complaint investigation was substantiated in part, with non-compliance found in resident care and related services. Some allegations were not supported by evidence.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the fall risk rating was reviewed and updated after a resident fall. |
| Facility failed to ensure all residents were assessed face to face using the uniform assessment instrument (UAI) prior to admission, annually, and with significant condition changes. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least annually and as needed for significant changes. |
| Facility failed to ensure personal assistance and care, including bathing at least twice a week or more often if needed, were provided as necessary. |
| Facility failed to ensure all resident records were kept current and retained at the facility. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Date to be corrected: Feb 21, 2025
Inspection Report
Monitoring
Census: 68
Deficiencies: 0
Nov 12, 2024
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services at the facility.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 68
Deficiencies: 2
Nov 12, 2024
Visit Reason
The inspection was a monitoring visit conducted on November 12, 2024, following a self-reported incident received on October 20, 2024, regarding allegations in the area of resident care and related services.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified during the inspection. The facility failed to ensure private pay uniform assessment instruments (UAIs) were completed as required and that the preliminary plan of care was signed and dated by the resident or legal representative.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required by 22VAC30-110. |
| The facility failed to ensure a preliminary plan of care was signed and dated by the resident or his legal representative. |
Report Facts
Number of residents present: 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
Inspection Report
Monitoring
Census: 68
Deficiencies: 1
Nov 12, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services following a self-reported incident received by VDSS regarding medication administration.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors. Violations were issued based on evidence that medications were not administered according to physician or prescriber instructions.
Deficiencies (1)
| Description |
|---|
| Medications were administered to the wrong resident, contrary to physician or prescriber instructions. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 62
Deficiencies: 2
Sep 17, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards.
Findings
The inspection found non-compliance with applicable standards, including failure to report a major incident within 24 hours and failure to administer medications according to physician orders.
Deficiencies (2)
| Description |
|---|
| The facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| The facility failed to ensure medications were administered in accordance with the physician's or prescriber's instructions. |
Report Facts
Number of residents present: 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
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 6
Sep 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-28 regarding allegations related to resident care and additional requirements for facilities caring for residents with serious cognitive impairments.
Findings
The investigation supported some but not all allegations of non-compliance in the areas of resident care and related services and additional requirements for facilities caring for residents with serious cognitive impairments. Multiple violations were identified including lack of designated staff for structured activities, incomplete preliminary plans of care, incomplete individualized service plans, insufficient scheduled activities, incomplete activity schedules, and inadequate oversight of special diets.
Complaint Details
The complaint investigation was substantiated in part, supporting some but not all allegations related to resident care and additional requirements for residents with serious cognitive impairments.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure a designated staff person responsible for managing or coordinating the structured activities program was on site at least 20 hours a week in the special care unit. |
| Facility failed to develop a preliminary plan of care on or within seven days prior to admission to address basic resident needs. |
| Facility failed to complete a comprehensive individualized service plan within 30 days after admission that included all identified needs such as diabetic diet. |
| Facility failed to ensure at least 14 hours of scheduled activities were available to residents each week for no less than one hour each day in the assisted living section. |
| Facility failed to keep the schedule of activities for the past two years at the facility. |
| Facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for residents with special diets. |
Report Facts
Residents present: 62
Resident records reviewed: 2
Staff interviews conducted: 1
Resident interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 1
Jul 16, 2024
Visit Reason
The inspection was a monitoring visit conducted on July 16, 2024, following a self-reported incident received on May 29, 2024, regarding allegations in personnel and resident care and related services.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified, including failure to submit a written incident report to the regional licensing office within seven days as required.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure submission of a written report of each incident to the regional licensing office within seven days from the date of the incident, including actions to prevent recurrence. |
Report Facts
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
Inspection Report
Monitoring
Deficiencies: 2
Jun 26, 2024
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws related to administration, resident care, and related services at the assisted living facility.
Findings
The inspection found non-compliance with standards including failure to document analysis and interventions after a resident fall, and failure to implement the medication management plan regarding timely transcription of medication orders to medication administration records.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure documentation of analysis and interventions following a resident fall to prevent or reduce risk of subsequent falls. |
| Facility failed to implement medication management plan requiring verification that medication orders are accurately transcribed to medication administration records within 24 hours of receipt. |
Report Facts
Date of resident fall: May 22, 2024
Date of physician's orders: May 29, 2024
Date of physician's orders: May 30, 2024
Inspection Report
Monitoring
Deficiencies: 1
May 7, 2024
Visit Reason
The inspection was conducted via phone on 05/07/2024 to verify evidence for the violation of the standard cited in the notice regarding the facility's acting administrator status.
Findings
The inspection determined non-compliance with the standard that the facility has been operated by an acting administrator for longer than 150 days, as verified by staff and documentation.
Deficiencies (1)
| Description |
|---|
| Facility is currently being operated by an acting administrator for longer than 150 days. |
Report Facts
Days acting administrator in place: 150
Inspection Report
Complaint Investigation
Deficiencies: 3
May 2, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 05/02/2024 regarding allegations in the areas of personnel, staffing and supervision, and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in resident care and related services. Violations included failure to implement the written staffing plan, improper medication handling, and failure to administer medications according to physician orders.
Complaint Details
The complaint was partially substantiated; evidence supported some allegations related to resident care and related services but not all. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (3)
| Description |
|---|
| Facility failed to implement its written staffing plan specifying the number and type of direct care staff required to meet day-to-day routine needs and special resident needs. |
| Facility failed to ensure medications remained in pharmacy-issued containers with prescription labels until administered to residents. |
| Facility failed to ensure medications were administered in accordance with physician or prescriber instructions. |
Report Facts
Direct care staff required per shift: 7
Direct care staff required per shift: 7
Direct care staff required per shift: 5
Direct care staff on duty: 6
Direct care staff on duty: 6
Direct care staff on duty: 6
Residents with prepoured medications observed: 7
Residents with medication administration errors: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the inspection and authored the report |
| Staff person 1 | Registered medication aide who prepoured medications and failed to administer them before shift end; employment terminated following complaint | |
| Staff person 3 | Provided staffing plan and confirmed staffing records |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-04-05 regarding allegations related to personnel and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of personnel, specifically failure to ensure mandated reporters reported suspected abuse or neglect as required by Virginia law.
Complaint Details
A complaint was substantiated in part; evidence showed that staff person 4 yelled at a resident concerning medication administration and that this incident was not reported to the local Adult Protective Services Agency as required by law.
Deficiencies (1)
| Description |
|---|
| Failure 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. |
Report Facts
Inspection duration: 2.5
Complaint receipt date: Apr 5, 2024
Inspection Report
Monitoring
Deficiencies: 0
Apr 17, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of personnel and resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the premises.
Inspection Report
Monitoring
Deficiencies: 0
Mar 13, 2024
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review compliance with resident care and related services standards.
Findings
The inspection found no violations of applicable standards or laws. The evidence gathered determined the facility was in compliance with regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-03-08 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint investigation related to allegations in resident care and related services; the complaint was not substantiated.
Inspection Report
Monitoring
Deficiencies: 1
Mar 13, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 03/12/2024 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to medication administration. The facility failed to ensure medications were administered according to physician orders, specifically missing three doses of Oxycodone-Acetaminophen for a resident due to medication unavailability.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure medications were administered in accordance with the physician's instructions, resulting in a resident missing three scheduled doses of Oxycodone-Acetaminophen due to medication unavailability. |
Report Facts
Missed medication doses: 3
Inspection Report
Complaint Investigation
Deficiencies: 7
Feb 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2024-02-14 regarding allegations in the area of resident care and related services at TerraBella Pheasant Ridge.
Findings
The investigation supported the allegations of non-compliance with multiple standards related to resident care, including failure to report major incidents within 24 hours, failure to update fall risk ratings after falls, failure to analyze falls and implement interventions, failure to ensure residents' healthcare service needs were met, failure to keep resident records current, failure to obtain new medication orders after hospitalizations, and failure to administer medications according to physician orders.
Complaint Details
The complaint investigation was substantiated as the evidence supported allegations of non-compliance with multiple regulatory standards related to resident care and services.
Deficiencies (7)
| Description |
|---|
| Failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Failed to ensure that the fall risk rating was reviewed and updated after a fall. |
| Failed to document analysis of the circumstances of falls and interventions initiated to prevent or reduce risk of subsequent falls. |
| Failed to ensure that the health care service needs of residents were met, including missed medical appointments and lack of follow-up. |
| Failed to keep all resident records current, including missing physician progress notes and emergency department documentation. |
| Failed to obtain new orders for medications and treatments after hospitalizations and ensure primary physician awareness. |
| Failed to administer medications in accordance with physician or prescriber instructions, including missed doses and lack of timely prescriptions. |
Report Facts
Inspection days: 2
Plan of correction submission timeframe: 5
Plan of correction correction timeframe: 24
Scheduled refresher courses: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff person 1 | Interviewed staff member confirming multiple deficiencies related to resident care and record keeping |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 13, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-02-09 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint received on 2024-02-09 regarding allegations in resident care and related services; investigation did not substantiate the allegations.
Inspection Report
Renewal
Census: 65
Deficiencies: 8
Jan 23, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure direct care staff had current first aid certification, incomplete or outdated resident assessments and individualized service plans, medication management deficiencies, incomplete documentation of resident rounds, and lack of semi-annual emergency preparedness review.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure each direct care staff member had current certification in first aid within 60 days of employment. |
| Residents were not assessed face to face annually using the uniform assessment instrument (UAI) as required. |
| Comprehensive Individualized Service Plans (ISP) were not completed within 30 days after admission for some residents. |
| Individualized Service Plans (ISP) were not reviewed and updated at least once every 12 months. |
| Medication management plan did not address procedures to prevent use of outdated, damaged, or contaminated medications; an opened insulin pen lacked an open date. |
| Medications were administered not in accordance with physician's or prescriber's instructions, including discontinued medications being given. |
| Facility failed to document rounds including resident name, date/time, and staff member for residents unable to use signaling device. |
| Facility failed to implement and document a semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers. |
Report Facts
Number of residents present: 65
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the inspection |
| Staff person 5 | Interviewed staff who confirmed multiple deficiencies including lack of first aid certification for staff person 1, incomplete assessments and ISPs, and emergency preparedness review absence |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-10-05 regarding allegations in the areas of Admission, Retention, and Discharge of Residents.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified concerning staff qualifications for direct care duties.
Complaint Details
The complaint was not substantiated based on the evidence gathered during the investigation.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure staff performing direct care duties met one of the requirements in the relevant subsection. |
Report Facts
Date of complaint received: Oct 5, 2023
Date of inspection: Oct 23, 2023
Date staff person 2 hired: May 26, 2022
Number of stairs resident was carried up: 8
Number of staff persons involved in transport: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-09-20 regarding allegations in the areas of Resident Care and Related Services and Buildings and Ground.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint was received on 2023-09-20 regarding Resident Care and Related Services and Buildings and Ground. The allegations were not substantiated by the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-09-05 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
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 publicly and a copy of the findings is required to be posted on the facility premises.
Complaint Details
Complaint received on 2023-09-05 regarding Resident Care and Related Services and Buildings and Grounds; allegations were not substantiated.
Inspection Report
Monitoring
Deficiencies: 0
May 19, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with licensing standards and resident care regulations.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Inspection Report
Monitoring
Deficiencies: 0
Mar 16, 2023
Visit Reason
The inspection was a monitoring visit conducted to review personnel and admission, retention, and discharge of residents standards.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 8, 2023
Visit Reason
The inspection was conducted in response to multiple complaints received by VDSS Division of Licensing regarding allegations in 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.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings did not substantiate the complaints.
Complaint Details
Complaints were received on 12/07/2022, 01/03/2023, 02/01/2023, and 02/06/2023 regarding multiple areas of concern. The evidence gathered did not support the allegations of non-compliance.
Inspection Report
Renewal
Census: 69
Deficiencies: 16
Feb 8, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for TerraBella Pheasant Ridge assisted living facility.
Findings
The inspection identified multiple deficiencies related to resident assessments, individualized service plans, medication administration, facility safety, and compliance with licensing terms. The facility was found non-compliant in areas including cognitive impairment assessments, fall risk updates, medication self-administration, and emergency preparedness.
Deficiencies (16)
| Description |
|---|
| Failed to ensure prior to admission to a safe, secure environment, resident was assessed by an independent physician for serious cognitive impairment. |
| Failed to obtain written approval from approving party prior to placing resident with serious cognitive impairment in a safe, secure environment. |
| Failed to document written determination and justification for placement in special care unit for residents with serious cognitive impairment. |
| Failed to review and update fall risk rating after resident falls. |
| Failed to complete uniform assessment instrument (UAI) accurately for private pay individuals. |
| Failed to ensure comprehensive individualized service plan (ISP) included all identified needs. |
| Failed to include hospice care services provided on individualized service plan (ISP). |
| Failed to ensure care and services specified in individualized service plan (ISP) were provided to each resident. |
| Failed to ensure residents capable of self-administering medication were permitted to keep medication in an out-of-sight place in their room. |
| Failed to ensure medications were administered according to physician's orders and standards of practice. |
| Failed to ensure use of PRN medications met regulatory requirements including physician orders detailing symptoms, dosage, and administration instructions. |
| Failed to post 'No Smoking-Oxygen in Use' signs in rooms where oxygen is in use. |
| Failed to ensure operable windows were effectively screened. |
| Failed to maintain hot water taps within required temperature range of 105 to 120 degrees Fahrenheit. |
| Failed to store cleaning supplies and hazardous materials in a locked area. |
| Failed to operate within the terms of its license regarding non-ambulatory residents residing on floors not permitted for such residents. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 5
Number of staff interviews conducted: 3
Water temperature readings: 94.1
Water temperature readings: 104
Water temperature readings: 91.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the inspection |
| Staff 7 | Staff interviewed and referenced multiple times in findings related to resident care and assessments | |
| Staff 8 | Staff observed administering medication and involved in medication administration deficiency | |
| Director of Health and Wellness | Named in multiple plans of correction related to addressing deficiencies |
Inspection Report
Monitoring
Deficiencies: 14
Nov 30, 2022
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and regulations at TerraBella Pheasant Ridge assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including lack of protective devices on windows in the secure unit, incomplete resident disclosure statements, inadequate staff orientation and training, missing tuberculosis risk assessments, incomplete resident admission interviews, incomplete physical examinations, failure to update fall risk ratings after resident falls, failure to conduct sex offender screenings, lack of resident orientation documentation, medication management policy implementation issues, unsafe storage of hazardous materials, building maintenance deficiencies, and incomplete staff employment records such as sworn disclosure statements and criminal history reports.
Deficiencies (14)
| Description |
|---|
| Facility failed to ensure 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. |
| Facility failed to ensure that the disclosure statement contained all required components. |
| Facility failed to ensure a staff person received the required orientation and training within the first seven working days of employment. |
| Facility failed to ensure a staff person submitted the results of a tuberculosis risk assessment prior to contact with residents. |
| Facility failed to ensure a documented interview between the administrator or designee and the potential resident and legal representative was conducted. |
| Facility failed to ensure the physical examination required within 30 days preceding admission contained all required components. |
| Facility failed to review and update the fall risk rating for a resident after the resident had fallen. |
| Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender. |
| Facility failed to ensure an acknowledgment was signed and dated that an orientation for new residents and their legal representatives was provided upon admission. |
| Facility failed to ensure the medication management policy was implemented, specifically missing dates on opened insulin pens. |
| Facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. |
| Facility failed to ensure that the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. |
| Facility failed to ensure that the sworn disclosure statement was completed for all applicants for employment. |
| Facility failed to ensure that the criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
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
Timeframe for plan of correction submission: 5
Timeframe for review request: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff 2 | Staff member who had not received required orientation and training and lacked tuberculosis risk assessment | |
| Staff 3 | Staff member interviewed confirming deficiencies related to staff training, tuberculosis screening, resident interviews, and sex offender screening | |
| Staff 4 | Staff member interviewed regarding medication management and fall risk rating deficiencies | |
| Staff 7 | Staff member who observed medication cart issues | |
| Executive Director | Named in multiple plans of correction related to education, audits, and compliance | |
| Maintenance Director | Named in plans of correction related to building maintenance and safety | |
| Business Office Manager | Named in plans of correction related to staff records, sworn disclosure statements, and audits | |
| Sales Director | Named in plans of correction related to resident orientation and sex offender screening education | |
| Director of Health and Wellness | Named in plans of correction related to resident physical exams, fall risk ratings, and medication management | |
| Marketing Director | Named in plans of correction related to admissions interview process |
Inspection Report
Original Licensing
Census: 65
Deficiencies: 3
Aug 26, 2022
Visit Reason
Initial licensing inspection conducted to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with standards related to facility maintenance, including broken switchplate, peeling wallpaper in memory care hallways, and wood damage at the kitchen exit door frame.
Deficiencies (3)
| Description |
|---|
| Facility failed to have the interior and exterior maintained in good condition, including a broken switchplate 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. |
Report Facts
Number of residents present: 65
Number of staff records reviewed: 9
Number of interviews conducted: 4
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