Safety Report: Pheasant Ridge Nursing and Rehabilitation

Roanoke, Virginia · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay quality★★★★★

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

4Immediate jeopardy citations (severity J–L)
6Actual harm citations (severity G–I)
7Requirements cited on more than one inspection
J
Government finding: Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of July 28, 2026, during a complaint investigation. Facility reported correction by September 8, 2026.
Administration Deficiencies · Tag F770
J
Government finding: Ensure that residents are free from significant medication errors.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of July 28, 2026, during a complaint investigation. Facility reported correction by September 8, 2026.
Pharmacy Service Deficiencies · Tag F760
J
Government finding: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of July 28, 2026, during a complaint investigation. Facility reported correction by September 8, 2026.
Resident Rights Deficiencies · Tag F580
G
Government finding: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of July 28, 2026, during a complaint investigation. Facility reported correction by September 8, 2026.
Nursing and Physician Services Deficiencies · Tag F726
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of July 28, 2026, during a complaint investigation. Facility reported correction by September 8, 2026.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
G
Government finding: Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 7, 2026, during a complaint investigation. Facility reported correction by September 8, 2026.
Administration Deficiencies · Tag F776
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 7, 2026, during a complaint investigation. Facility reported correction by June 17, 2026.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 7, 2026, during a complaint investigation. Facility reported correction by June 17, 2026.
Quality of Life and Care Deficiencies · Tag F692
G
Government finding: Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 7, 2026, during a complaint investigation. Facility reported correction by June 17, 2026.
Resident Assessment and Care Planning Deficiencies · Tag F658
J
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 21, 2024, during a complaint investigation. Facility reported correction by February 18, 2025.
Quality of Life and Care Deficiencies · Tag F684

Citations by topic

2Abuse, neglect & exploitation
0Infection control
5Medications & pharmacy
1Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

More citations in the most recent cycle (29) than in the cycle before (14).

Two cycles ago
none serious
Prior cycle
1 serious
Most recent cycle
9 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684)5July 28, 2026; May 7, 2026; November 21, 2024; January 19, 2024; April 8, 2021
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842)4May 7, 2026; November 21, 2024; January 19, 2024; August 3, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580)3July 28, 2026; November 21, 2024; January 19, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable. (F677)3July 28, 2026; January 19, 2024; August 3, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812)2July 28, 2026; January 19, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755)2July 28, 2026; November 21, 2024
Ensure services provided by the nursing facility meet professional standards of quality. (F658)2July 28, 2026; May 7, 2026

Fines and enforcement

DateTypeAmount / length
May 7, 2026Fine$191,957

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

44 citations across 6 inspection dates.

July 28, 2026 — 12 citations (includes serious) · complaint investigation
J
Provide timely, quality laboratory services/tests to meet the needs of residents.
Immediate jeopardy to resident health or safety · Isolated · Administration Deficiencies · F770 · complaint · corrected September 8, 2026
J
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected September 8, 2026
J
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Immediate jeopardy to resident health or safety · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected September 8, 2026
G
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Actual harm to a resident (not immediate jeopardy) · Isolated · Nursing and Physician Services Deficiencies · F726 · complaint · corrected September 8, 2026
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected September 8, 2026
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · complaint · corrected September 8, 2026
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · complaint · corrected September 8, 2026
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected September 8, 2026
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected September 8, 2026
E
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · complaint · corrected September 8, 2026
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected September 8, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected September 8, 2026
May 7, 2026 — 7 citations (includes serious) · complaint investigation
G
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Actual harm to a resident (not immediate jeopardy) · Isolated · Administration Deficiencies · F776 · complaint · corrected September 8, 2026
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected June 17, 2026
G
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F692 · complaint · corrected June 17, 2026
G
Ensure services provided by the nursing facility meet professional standards of quality.
Actual harm to a resident (not immediate jeopardy) · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected June 17, 2026
E
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F773 · complaint · corrected September 8, 2026
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected September 8, 2026
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected September 8, 2026
November 21, 2024 — 10 citations (includes serious) · complaint investigation
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected February 18, 2025
E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F711 · complaint · corrected February 18, 2025
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected February 18, 2025
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected January 15, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · complaint · corrected February 18, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected February 18, 2025
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · complaint · corrected February 18, 2025
D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F635 · complaint · corrected February 18, 2025
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected February 18, 2025
D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F573 · complaint · corrected January 15, 2025
January 19, 2024 — 10 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected February 21, 2024
E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · corrected February 21, 2024
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected February 21, 2024
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected February 21, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected February 21, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected February 21, 2024
D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F661 · complaint · corrected February 21, 2024
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected February 21, 2024
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected February 21, 2024
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · corrected February 21, 2024
August 3, 2022 — 4 citations
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected September 7, 2022
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected September 7, 2022
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected September 7, 2022
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected September 7, 2022
April 8, 2021 — 1 citation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected April 27, 2021

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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