Pheasant Ridge Nursing and Rehabilitation
4355 Pheasant Ridge Road, Roanoke, VA 24014 · Roanoke City County · 101 certified beds · avg 88 residents/day · certified since Jan 1, 1998
Part of chain: AVARDIS HEALTH (38 facilities, chain avg rating 2.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 21, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 7, 2026 · F-0658 · triggered by a complaint
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2026 (Deficient, Provider has plan of correction)
▲ Actual harm, one-off · May 7, 2026 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2026 (Deficient, Provider has plan of correction)
▲ Actual harm, one-off · May 7, 2026 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2026 (Deficient, Provider has plan of correction)
▲ Actual harm, one-off · May 7, 2026 · F-0776 · triggered by a complaint
The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them.
Why it matters: Delayed x-rays can postpone the diagnosis of fractures, pneumonia, and other urgent conditions.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2026 (Deficient, Provider has plan of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 7, 2026 | ▲ G · Actual harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| May 7, 2026 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| May 7, 2026 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| May 7, 2026 | ▲ G · Actual harm, one-off | The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Nov 21, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jan 19, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 19, 2024 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Jan 19, 2024 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jan 19, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Aug 3, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 3, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 3, 2022 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Aug 3, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 8, 2021 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 1 | 0 | D |
| 2022 | 4 | 0 | D |
| 2024 | 20 | 1 | J ▲ |
| 2026 | 7 | 4 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.45 | 3.67 | 3.95 | top 43% in Virginia; bottom 34% in the U.S. |
| Registered Nurse hours | 0.67 | 0.66 | 0.69 | top 25% in Virginia; top 39% in the U.S. |
| Weekend total nurse staffing | 3.02 | 3.21 | 3.50 | top 44% in Virginia; bottom 32% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.43 | 0.46 | 0.48 | top 30% in Virginia; top 44% in the U.S. |
| Total nursing staff turnover (%) | 53.8 | 48.1 | 45.8 | bottom 37% in Virginia; bottom 28% in the U.S. |
| RN turnover (%) | 53.3 | 48.2 | 42.9 | bottom 41% in Virginia; bottom 31% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.27, RN 0.64, weekend 2.86. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 3/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Mill Mountain Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2025 |
| SW Roanoke Parentco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/2025 |
| Vaop Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2025 |
| Brandt, Karen | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/05/2025 |
| Brandt, Karen | Individual | ADP of the SNF | NOT APPLICABLE | 07/05/2025 |
| Clark, Alyssa | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2025 |
| Clark, Alyssa | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Clark, Alyssa | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Forren, Holly | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Forren, Holly | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Hoback, Tiffany | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2025 |
| Hoback, Tiffany | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Hoback, Tiffany | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Jones, Tequilla | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Jones, Tequilla | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| SNF Mgr LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| SNF Mgr LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/17/2025 |
| Tompkins, Paul | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Tompkins, Paul | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "If a resident needs an x-ray, how is it done and how long does it usually take?"
- "When a doctor orders lab work, how quickly is it done and how are results communicated back?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How often does each resident's doctor visit and review their care in person?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| South Roanoke Nursing and Rehabilitation | 0.9 mi | Roanoke, VA | ★★★☆☆ | 2/5 | |
| Friendship Health and Rehab Center - South | 1.9 mi | Roanoke, VA | ★★★☆☆ | 3/5 | |
| Old Southwest Health and Rehabilitation | 2.7 mi | Roanoke, VA | ★☆☆☆☆ | 1/5 | |
| Raleigh Court Health and Rehabilitation Center | 2.9 mi | Roanoke, VA | ★★★★☆ | 3/5 | |
| Brandon Oaks Nursing and Rehabilitation Center | 4.0 mi | Roanoke, VA | ★★★★★ | 4/5 | |
| Our Lady of the Valley | 4.0 mi | Roanoke, VA | ★★★★☆ | 4/5 | |
| Davis and McDaniel Veterans Care Center | 4.8 mi | Roanoke, VA | ★★★★★ | 5/5 | |
| Salem Health & Rehabilitation | 4.9 mi | Salem, VA | ★☆☆☆☆ | 2/5 | |
| Berkshire Health & Rehabilitation Center | 5.4 mi | Vinton, VA | ★★★★☆ | 4/5 | |
| Star City Rehabilitation and Nursing | 6.0 mi | Roanoke, VA | ★★☆☆☆ | 3/5 | |
| Springtree Healthcare & Rehab Center | 6.7 mi | Roanoke, VA | ★★★☆☆ | 3/5 | |
| Friendship Health and Rehab Center | 7.0 mi | Roanoke, VA | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 495325.