Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pheasant Ridge Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a DNR order and intact cognition experienced a sudden decline, including lethargy and labored breathing. Despite the resident's son requesting hospital transfer, staff did not initiate emergency transport or provide timely interventions, and the resident died hours later. Documentation and interviews revealed confusion among staff about the resident's care preferences, and the facility failed to follow its own policy for responding to significant changes in condition.
Facility staff did not ensure that medical provider orders entered by non-prescribing staff were signed by the prescribers, resulting in multiple unsigned orders for medications, therapies, and laboratory tests for several residents. The facility's policy requires timely provider signatures on all orders, but this was not consistently followed, as confirmed by record reviews and staff interviews.
Facility staff did not provide a resident's clinical record to an authorized representative within the required timeframe, despite documentation of a valid POA authorizing access. The request was denied due to the facility's insistence on additional proof of authority, even though the representative's rights were documented in the resident's records. The resident had expired and was previously assessed as cognitively intact.
Facility staff failed to promptly notify the provider after a resident with complex medical conditions experienced significant weight loss, with no documentation of provider notification at the time of the event. In a separate case, staff did not promptly inform a resident representative when another resident experienced a marked decline in condition, with notification occurring more than two hours after the initial symptoms were documented. Both incidents were contrary to facility policy requiring timely notification and documentation of significant changes in resident status.
A resident with intact cognition was admitted with a hospital discharge order for Prednisone on a tapering schedule for ulcerative pancolitis. Facility staff did not promptly order the medication upon admission, resulting in a missed dose on the second day. No documentation was found to explain the omission, despite facility policy requiring timely transcription and confirmation of admission medication orders.
Facility staff did not develop or implement baseline care plans within 48 hours of admission for three residents, including individuals with complex medical and mental health needs. Despite requests, the DON and leadership were unable to locate the required documentation, which is mandated by facility policy to ensure person-centered care upon admission.
Facility staff did not develop or implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, despite assessment findings indicating needs in areas such as pain management, incontinence, pressure ulcer risk, and therapy services. The care plan on record addressed only limited issues and omitted several critical areas identified in the assessment, with staff unable to provide a complete care plan when requested.
Facility staff did not provide a resident with ordered oxygen therapy at bedtime and failed to transcribe an order for a flutter valve breathing device following hospital discharge for acute respiratory failure with hypoxia. The resident did not receive the prescribed respiratory interventions, and staff documented administration of oxygen that was not actually provided.
Facility staff failed to ensure that a prescribed Narcan nasal spray, dispensed for a specific resident, was available when it was administered to another resident without proper documentation or replacement. The nurse practitioner obtained and administered the nasal spray from the medication cart, and staff could not identify the original recipient or provide evidence that the medication was replaced or the pharmacy notified.
Staff failed to maintain complete and accurate clinical records for a resident who experienced a decline and died. Documentation was missing or incomplete regarding Narcan administration, oxygen delivery, and vital signs, with some vital signs recorded at incorrect times. Progress notes from the nurse practitioner and Medical Director were either delayed or absent, despite involvement in care decisions.
Failure to Provide Timely Emergency Care and Honor Resident's Preferences Following Change in Condition
Penalty
Summary
Facility staff failed to appropriately respond to a significant decline in a resident's condition, which included symptoms such as lethargy, decreased responsiveness, clammy skin, and Cheyne-Stokes respirations. The resident, who had a DNR order but no other documented care limitations, was noted to have intact cognition and diagnoses including coronary artery disease, hypertension, and paroxysmal atrial fibrillation. Despite the resident's sudden decline, there was no evidence that staff checked the resident's blood sugar or initiated timely emergency transport. Clinical documentation showed that the nurse practitioner administered Narcan despite the resident refusing opioid medications, and applied oxygen for comfort, but did not document the amount or delivery device. Communication with the resident's son revealed that he requested hospital transfer after being informed of his father's condition, but there was no evidence that staff made any effort to arrange for transport. Staff interviews and progress notes indicated confusion regarding the resident's wishes, with some staff believing the son agreed to keep the resident at the facility, while the son stated he requested hospital transfer and did not agree to keep his father at the facility. The facility's own policy required prompt notification and emergency response in the event of a significant change in condition, including calling 911 and notifying the physician and resident representative. However, documentation and interviews confirmed that no emergency transport was initiated, and the resident died approximately four hours after the initial decline was documented. There was also a lack of timely and accurate documentation by the medical director and nurse practitioner regarding the resident's care preferences and actions taken.
Failure to Obtain Provider Signatures on Medical Orders
Penalty
Summary
Facility staff failed to ensure that medical provider orders were signed by the prescribing providers when orders were entered into residents' clinical records by non-prescribing staff. Clinical record reviews revealed multiple instances where orders, including those for medications, laboratory tests, and therapies, were not signed by the medical providers who issued them. The facility's own policy requires that both admission and routine orders be reviewed, signed, and dated by the prescribing provider as soon as practicable to maintain an accurate medical record. However, several orders for different residents, including those for barrier cream, CPAP therapy, dietary modifications, medications such as oxycodone and levofloxacin, and laboratory tests, remained unsigned by the respective prescribers. Interviews with the Medical Director confirmed that they had given orders throughout the year but could not specify the last time they had signed orders entered by facility staff. The Director of Nursing was made aware of the issue but had not yet determined the full extent of unsigned provider orders at the time of the survey. The deficiency was identified through interviews, clinical record reviews, and examination of facility documentation.
Failure to Timely Provide Resident Records to Authorized Representative
Penalty
Summary
Facility staff failed to provide a copy of a resident's clinical record to the resident's representative within the required two working days after a request was made. The request was made by the resident's representative, who was documented in the clinical record as holding a Durable General Power of Attorney (POA) with explicit authorization to request, receive, and review the resident's medical and hospital records. Despite this documentation, the facility declined the request, citing a lack of supporting documentation to prove authority to access the records on the resident's behalf. The facility's documentation showed that the request was forwarded to the legal department, and a denial letter was sent to the representative, stating the request was incomplete due to missing proof of authority. An email from the Administrator reiterated the denial, specifying that proof of authority, such as a death certificate and identification, was required. The resident in question had expired while at the facility and was assessed as cognitively intact or borderline, with a BIMS score of 14 out of 15. The facility's own policy defined a personal representative as someone authorized under state or applicable law to act on behalf of the individual in making health care decisions and to exercise the individual's rights.
Failure to Promptly Notify Provider and Resident Representative of Significant Change in Condition
Penalty
Summary
Facility staff failed to promptly notify the medical provider after a resident with multiple complex medical diagnoses, including gastrointestinal disorders and diabetes, experienced a significant weight loss. The resident's weight dropped from 161.0 lbs to 139.2 lbs over a period of less than two months, which was identified as a nutritionally significant loss by the dietician. Despite this, there was no documentation that the provider was notified of the weight loss at the time it was first recorded, and the only related note was from the dietician nearly a month later. The Director of Nursing confirmed that no evidence of provider notification was found for the date of the significant weight loss. In a separate incident, staff did not promptly notify a resident representative when another resident experienced a notable decline in condition. The resident, who was assessed as cognitively intact, was documented as having increased somnolence, lethargy, clammy skin, swallowing problems, and shallow respirations over the course of several hours. Although the nurse practitioner was notified of some changes, there was no documentation that the resident representative was informed of the decline until more than two hours after the initial assessment of increased somnolence and other symptoms. Facility policy required prompt notification of the attending physician and resident representative in the event of significant changes in a resident's physical, mental, or psychosocial status, and for such notifications to be documented in the medical record. In both cases, the required notifications were either delayed or not documented, resulting in a failure to follow established procedures for changes in resident condition.
Failure to Timely Continue Hospital-Ordered Medication at Admission
Penalty
Summary
Facility staff failed to ensure that a medication ordered to be continued after hospital discharge was promptly ordered upon admission for a resident. Specifically, Prednisone, which was prescribed on a tapering schedule for ulcerative pancolitis with complications, was not ordered until the resident's second day at the facility. As a result, the resident missed a scheduled dose of Prednisone on their second day. There was no documentation provided or found to explain why this medication was not included in the admission medication orders. The resident was assessed as having intact or borderline cognition, with a BIMS score of 14 out of 15, and was able to make themselves understood and understand others. The hospital discharge summary clearly indicated the need for Prednisone to be continued, and the facility's policy required that physician orders be reviewed, verified, and transcribed to the medical record upon admission. Despite this, the order for Prednisone was not written until the second day, to be started on the third day, resulting in a missed dose.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by facility policy. For one resident with multiple complex diagnoses including sepsis, diabetes, sleep apnea, anxiety, depression, dementia, and COVID-19, no baseline care plan was found in the clinical record. This resident was also noted to have severe cognitive impairment, incontinence, a colostomy, pressure ulcers, surgical wounds, and was on isolation. Despite requests, the Director of Nursing (DON) was unable to provide the baseline care plan, stating that such plans were kept on paper by unit managers but could not be located. Similarly, another resident with diagnoses including schizophrenia, depression, diabetes, COVID-19, hypertension, and colon cancer, and who was at risk for pressure ulcers and had a surgical wound, also did not have a baseline care plan in the record. This resident experienced frequent pain and was on multiple medications, including opioids, antipsychotics, antidepressants, and diuretics. A third resident, assessed as having intact or borderline cognition, also lacked a baseline care plan in their clinical record. In all cases, the DON and facility leadership confirmed that the required baseline care plans could not be found, despite the facility's policy mandating their development and implementation within 48 hours of admission.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for one resident. The resident had multiple diagnoses, including a right hip fracture with surgical repair, protein calorie malnutrition, diabetes, chronic kidney disease, anemia, breast cancer, and hypertension. The Minimum Data Set (MDS) assessment indicated mild cognitive impairment, frequent incontinence, severe pain interfering with daily activities, insulin injections, risk for pressure ulcers, a surgical wound, and ongoing therapy services. The Care Area Assessment (CAA) worksheets identified the need for care plans addressing vision, communication, functional abilities, urinary incontinence, falls, pressure ulcers/injury, and pain. Upon review, the resident's care plan only included focuses for COVID-19, activities, discharge planning, nutrition, and do not resuscitate orders, with no evidence of care plans for the other identified needs. When asked, the Director of Nursing was unable to provide a comprehensive care plan and acknowledged a miscommunication regarding responsibility for care plan development. The facility's policy requires an individualized, person-centered plan of care developed by the interdisciplinary team, but this was not followed for the resident in question.
Failure to Provide Ordered Respiratory Care and Oxygen Therapy
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident with a diagnosis of acute respiratory failure with hypoxia. The resident had a physician's order for oxygen at 2 liters via nasal cannula at bedtime for shortness of breath, as well as a hospital discharge summary indicating the need for continued use of a flutter valve breathing device after discharge. However, the order for the flutter valve was not transcribed into the resident's physician order summary, and the resident reported not having the device since leaving the hospital. Staff interviews confirmed that the resident was not using a flutter valve. Additionally, although the resident's baseline care plan and physician's order summary included an order for oxygen at bedtime, there was no oxygen concentrator observed in the resident's room, and both the resident and staff confirmed that oxygen had not been used since admission from the hospital. Despite this, the electronic treatment administration record showed that staff had been initialing oxygen as being administered per the physician's order. These findings were discussed with facility leadership, but no further information was provided prior to the survey exit.
Failure to Ensure Availability and Proper Administration of Prescribed Medication
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available to meet residents' needs when a Narcan nasal spray, dispensed by the pharmacy for a specific resident, was administered to another resident without proper documentation or replacement. The nurse practitioner administered two doses of Narcan nasal spray to a resident who did not have an order for it, and the staff could not identify which resident's medication was used. The Narcan nasal spray was not part of the facility's as-needed medication stock, which only included injectable Narcan, indicating that the nasal spray had been specifically dispensed for an individual resident. Interviews with staff revealed that the nurse practitioner obtained the Narcan nasal spray directly from the medication cart, and the staff were unable to provide evidence that the pharmacy was notified or that the medication was replaced for the intended resident. The Director of Nursing confirmed the lack of documentation and inability to identify the original recipient of the Narcan nasal spray, resulting in a failure to ensure the medication's availability for the resident it was prescribed to.
Incomplete and Inaccurate Clinical Record Documentation for Resident at Time of Decline and Death
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for one of nine sampled residents. The resident was assessed as having intact or borderline cognition and was able to communicate effectively. On the day of the resident's decline and subsequent death, documentation was incomplete and inaccurate: a nurse's note indicated administration of two doses of Narcan without specifying the route, the oxygen device, or the amount administered. Vital signs were documented at a time when they were not actually obtained, and the nurse confirmed that the recorded time was incorrect. Additionally, the clinical record lacked progress notes from the nurse practitioner or physician for the day of the resident's decline and death. Further review revealed that the nurse practitioner’s note was not provided until the afternoon of the following day and did not include times for when certain vital signs were obtained. The note also contained a respiratory rate documented after the resident's recorded time of death. The facility's policy required accurate and timely documentation of procedures and resident responses, which was not followed. The absence of a progress note from the Medical Director for the day in question was also noted, despite the Medical Director reporting involvement in care decisions and attempted communication with the resident's family.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roanoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Roanoke Nursing And Rehabilitation | 0.9 mi | — | 0 | 0 |
| Friendship Health And Rehab Center - South | 1.9 mi | — | 0 | 0 |
| Old Southwest Health And Rehabilitation | 2.7 mi | — | 0 | 0 |
| Raleigh Court Health And Rehabilitation Center | 2.9 mi | — | 0 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 4 mi | — | 0 | 0 |
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