Cycle 1
Health 2024-01-19 · Fire 2024-01-19
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Roanoke, VA
Pheasant Ridge Nursing and Rehabilitation
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4355 Pheasant Ridge Road, Roanoke, VA
(540) 725-8210
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Operator or chain grouping
Approved since
1998-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,206
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.87
Baseline 21.61% · Performance 19.18% · Measure score 4.87 · Achievement 4.87 · Improvement 4.81
Healthcare-associated infections
5.51
Baseline 8.25% · Performance 6.30% · Measure score 5.51 · Achievement 5.15 · Improvement 5.51
Total nurse turnover
3.08
Baseline 71.28% · Performance 54.67% · Measure score 3.08 · Achievement 2.20 · Improvement 3.08
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 166 · Observed rate 7.23% · Lower 95% interval 6.96% |
| Discharge to community | 47.08% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 42.11% · Lower 95% interval 38.73% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 129 · Denominator 129 |
| Falls with major injury | 1.55% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 129 |
| Discharge self-care score | 57.53% |
53.69%
3.8 pts better
|
Numerator 42 · Denominator 73 |
| Discharge mobility score | 60.27% |
50.94%
9.3 pts better
|
Numerator 44 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 3.88% |
2.29%
1.6 pts worse
|
Numerator 5 · Denominator 129 · Adjusted rate 3.64% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 4.46% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 40.24% |
8.2%
32 pts better
|
Numerator 33 · Denominator 82 |
| Staff flu vaccination coverage | 12.96% |
42%
29 pts worse
|
Numerator 14 · Denominator 108 |
| Discharge function score | 65.75% |
56.45%
9.3 pts better
|
Numerator 48 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 6 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
91.2%
2.1 pts worse
|
93.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 85.1% · Q3 85.9% · Q4 85.9% · 4Q avg 89.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.7% |
94.0%
7.3 pts worse
|
95.5%
8.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.5% · Q3 4.7% · Q4 7.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
15.7%
10.2 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 10.9% · Q4 8.6% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.7%
3 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.8% · Q3 3.8% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
20.2%
11.2 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 31.7% · Q3 30.2% · Q4 34.5% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
15.0%
5.4 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 21.1% · Q3 21.3% · Q4 19.5% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.0% |
17.5%
0.5 pts worse
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 23.3% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
15.7%
1.1 pts worse
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 9.1% · Q3 13.3% · Q4 17.6% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.6%
0.3 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 6.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
22.2%
0.8 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 19.3% · Q3 25.0% · Q4 22.8% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.2%
2.3 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 8.9% · Q3 5.3% · Q4 4.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
74.6%
0.7 pts better
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 69.2% · Q3 68.8% · Q4 79.7% · 4Q avg 75.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
11.7%
4 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.8% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.1% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.7% |
73.6%
13.9 pts worse
|
79.7%
20 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
22.0%
1.2 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 20.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-03 · Fire 2022-08-03
14 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-04-08 · Fire 2021-04-08
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-01-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-16
F · Potential for more than minimal harm
2022-08-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-08-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-08-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-08-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-05
F · Potential for more than minimal harm
2021-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-15
F · Potential for more than minimal harm
2021-04-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-06-15
F · Potential for more than minimal harm
2021-04-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-04-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-04-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-04-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-06-15
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-18
E · Potential for more than minimal harm
2024-11-21
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-21
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-11-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-21
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-11-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-18
F · Potential for more than minimal harm
2024-01-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-21
C · Minimal harm
2024-01-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-21
D · Potential for more than minimal harm
2022-08-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-07
D · Potential for more than minimal harm
2021-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-04-27
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
South Roanoke Nursing And Rehabilitation
Roanoke, VA
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Friendship Health And Rehab Center - South
Roanoke, VA
3-star overall rating with 3-star inspections with $8,281 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Old Southwest Health And Rehabilitation
Roanoke, VA
1-star overall rating with 1-star inspections with $143,823 in total fines with 46 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out
Supporting pages
City page
Best nursing homes in Roanoke, VA
See how this facility ranks inside its city.
11 facilitiesCounty
Roanoke City
County ranking page for nearby alternatives.
9 facilitiesChain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Chain page for the operating group.
36 facilities