Inspection Reports for
Pheasant Ridge Nursing and Rehab Center
4355 Pheasant Ridge Rd, Roanoke, VA 24014, USA, VA, 24014
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to respond timely to clinical record requests, failure to notify resident representatives and providers of changes in condition, medication ordering delays, lack of baseline and comprehensive care plans, and failure to provide appropriate emergency care and respiratory services.
Complaint Details
The complaint investigation focused on Resident #9's clinical record request delays, failure to notify representatives and providers of condition changes, medication ordering delays, lack of care plans, failure to provide emergency care resulting in death, respiratory care deficiencies, unsigned medical orders, medication replacement failures, and incomplete clinical documentation.
Findings
The facility failed to respond timely to clinical record requests, notify resident representatives and providers promptly of changes in condition, order medications timely, develop baseline and comprehensive care plans, provide appropriate emergency care resulting in a resident's death, ensure respiratory care per physician orders, maintain signed medical provider orders, and maintain complete and accurate clinical records.
Deficiencies (10)
F 0573: Facility staff failed to respond to a request for copies of Resident #9's clinical records within the required time frame.
F 0580: Facility staff failed to promptly notify Resident #9's representative and provider of significant changes in condition and weight loss for Resident #8.
F 0635: Facility staff failed to ensure medication (Prednisone) ordered to be continued after hospital discharge was promptly ordered for Resident #9.
F 0655: Facility staff failed to develop and implement baseline care plans for Residents #1, #7, and #9.
F 0656: Facility staff failed to develop and implement a comprehensive person-centered care plan for Resident #2.
F 0684: Facility staff failed to appropriately respond to a decline in condition for Resident #9, resulting in death; Immediate Jeopardy was identified and later removed after corrective actions.
F 0695: Facility staff failed to provide oxygen per physician's order and failed to transcribe an order for a flutter valve breathing device for Resident #101.
F 0711: Facility staff failed to ensure medical provider orders were signed by the provider when entered into residents' clinical records.
F 0755: Facility staff failed to ensure medication administered to Resident #9 (Narcan nasal spray) dispensed for another resident was replaced to ensure availability.
F 0842: Facility staff failed to maintain complete and accurate clinical records for Resident #9, including inaccurate vital sign documentation and missing progress notes.
Report Facts
Number of sampled residents: 9
Number of doses of Narcan administered: 2
Weight loss: 22
BIMS score: 14
BIMS score: 12
BIMS score: 3
BIMS score: 15
BIMS score: 13
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 11
Date: Jan 19, 2024
Visit Reason
Complaint investigation triggered by concerns regarding resident care, medication administration, discharge procedures, and facility operations.
Complaint Details
The investigation was complaint-driven, focusing on multiple resident care issues including medication errors, failure to follow physician orders, inadequate ADL care, discharge planning deficiencies, and facility operational concerns.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility, failure to notify physicians of care issues, inaccurate resident assessments, inadequate discharge planning, insufficient ADL care, medication administration errors, failure to maintain nurse staffing records, failure to act on pharmacist recommendations, improper food service sanitation, and incomplete clinical records.
Deficiencies (11)
F 0558: Facility staff failed to ensure the residents call system was within reach for 1 of 19 residents, Resident #15.
F 0580: Facility staff failed to notify the physician of failure to follow physician orders for 1 of 19 residents, Resident #71, who did not receive ordered showers.
F 0641: Facility staff failed to accurately document completion dates of resident interview sections of Minimum Data Set assessments for 1 of 27 residents, Resident #91.
F 0661: Facility staff failed to provide discharge information and follow-up contact for 1 of 8 discharged residents, Resident #91.
F 0677: Facility staff failed to provide adequate ADL care for 2 of 19 residents, Residents #15 and #84, including long toenails and fingernails with debris.
F 0684: Facility staff failed to administer Resident #91's blood pressure medication according to provider orders and failed to provide ordered showers for Resident #71.
F 0684: Facility staff failed to obtain physician's orders for care of surgical site for Resident #345.
F 0732: Facility staff failed to maintain 18 months of posted daily nurse staffing information and failed to clearly document daily resident census on 21 days.
F 0756: Facility staff failed to act upon a pharmacist recommendation for gradual dose reduction of psychotropic medication for Resident #50.
F 0812: Facility staff failed to properly clean the convection oven, high-temperature dishwasher, and stacked wet pans in the kitchen.
F 0842: Facility staff failed to ensure a complete and accurate clinical record for Resident #34, with conflicting medication administration orders.
Report Facts
Residents affected: 19
Residents affected: 27
Residents affected: 8
Days missing census: 21
Medication administration errors: 4
Pharmacy consultation dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Involved in multiple findings including medication administration, discharge planning, and pharmacy consultation discussions |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed call light placement and medication administration clarification for Resident #34 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Scheduled podiatry appointment for Resident #15 |
| District Dietary Manager | District Dietary Manager | Interviewed regarding kitchen sanitation and cleaning procedures |
| Business Office Manager | Business Office Manager | Interviewed regarding discharge paperwork for Resident #91 |
| Family Nurse Practitioner | Family Nurse Practitioner | Consulted about surgical site care for Resident #345 |
Inspection Report
Deficiencies: 2
Date: Jan 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and discharge procedures at Pheasant Ridge Nursing and Rehabilitation.
Findings
The facility failed to accurately document completion dates of resident interview sections of Minimum Data Set (MDS) assessments for one resident. Additionally, the facility failed to provide discharge information and follow-up contact for one discharged resident.
Deficiencies (2)
F0641: The facility staff failed to accurately document completion dates of resident interview sections of MDS assessments for Resident #91, with sections completed after the assessment reference dates.
F0661: The facility staff failed to provide discharge paperwork including post-discharge medication and care instructions, and did not provide follow-up contact for Resident #91 after discharge.
Report Facts
Residents assessed: 27
Discharged residents reviewed: 8
Resident affected: 1
Brief Interview for Mental Status score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Met with survey team regarding MDS assessment documentation and discharge procedures | |
| Director of Nursing | Met with survey team regarding MDS assessment documentation and discharge procedures | |
| Business Office Manager | Interviewed about discharge summary and instructions for Resident #91 |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, and clinical record accuracy at Pheasant Ridge Nursing and Rehabilitation.
Findings
The facility failed to provide adequate activities of daily living (ADL) care for two residents, failed to ensure accident hazard prevention for one resident, administered unnecessary medication to one resident, and failed to maintain accurate clinical records for two residents. Deficiencies were noted in ADL care, safety alarm use, medication administration, and documentation.
Deficiencies (4)
F 0677: Facility staff failed to provide ADL care for 2 of 18 residents, including long, thick fingernails and toenails for Resident #29 and inadequate bathing for Resident #68.
F 0689: Facility staff failed to ensure Resident #28 was free of accident hazards by not having physician-ordered wanderguard or chair alarm in place.
F 0757: Facility staff administered Metoprolol Tartrate to Resident #45 on four occasions when it should have been held per physician orders.
F 0842: Facility staff failed to maintain accurate clinical records for Residents #286 and #84, including incorrect documentation of an AV shunt and failure to obtain discharge inventory signature.
Report Facts
Residents in survey sample: 18
Metoprolol Tartrate administrations: 4
Fall risk assessment score: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Documented attempts to cut Resident #29's nails and signed medication administration records related to Resident #45 | |
| Licensed Practical Nurse (LPN) #3 | Documented refusal of nail clipping by Resident #29 | |
| Director of Nursing (DON) | Provided information and documentation related to multiple deficiencies including Resident #28's alarms, Resident #68's bathing, and Resident #45's medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 8, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to administer physician-ordered medication to a resident.
Complaint Details
The complaint investigation found that the medication was not administered to Resident #71 as ordered. The issue was substantiated with observations and staff interviews confirming the medication was left on the resident's tray and later discarded by nursing staff.
Findings
The facility staff failed to ensure Resident #71 consumed the prescribed medication Metoprolol, which was found on the resident's food tray, indicating it was not administered as ordered. The issue was acknowledged by nursing staff and facility leadership during the investigation.
Deficiencies (1)
F 0684: The facility staff failed to ensure Resident #71 consumed the medication Metoprolol as ordered. The medication was observed on the resident's food tray, indicating it was not administered per physician's orders.
Report Facts
Residents affected: 1
Medication dosage: 100
Medication administration times: 2
Blood pressure readings: 130
Blood pressure readings: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Identified the dropped medication and later discarded it | |
| Director of Nursing | Made aware of the medication administration issue | |
| Assistant Director of Nursing | Made aware of the medication administration issue | |
| Administrator | Made aware of the medication administration issue | |
| Regional Nurse Consultant | Made aware of the medication administration issue |
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