Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Pheasant Ridge Nursing and Rehabilitation
ROANOKE, VA · 101 certified beds · Last Life Safety survey January 19, 2024
CMS Certification Number 495325 · first certified January 1998
Ownership
Operated by AVARDIS HEALTH · For profit - Corporation
- New ownershipOwnership changed June 1, 2025 (change of ownership)from PHEASANT RIDGE FACILITY OPERATIONS, LLC
Position within VA
15 citations — more than 68% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to August 2027. This facility’s last Life Safety survey was January 2024. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 8, 2021 | 8 |
| August 3, 2022 | 5 |
| January 19, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2022-08-03 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2022-08-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2022-08-03 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2024-01-19 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2021-04-08 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2021-04-08 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2021-04-08 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2021-04-08 |
What the citations cover
- Smoke Deficiencies 5
- Egress Deficiencies 4
- Miscellaneous Deficiencies 2
- Services Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 19, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (February 16, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 16, 2024) |
August 3, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 5, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 5, 2022) |
April 8, 2021 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 15, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 29, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.