Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pheasant Ridge Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with CHF, COPD, malnutrition, depression/anxiety, cognitive impairment, and frequent severe pain had repeated pain complaints, but nursing documentation often lacked pain location, characteristics, and nonpharmacologic interventions, and TAR/MAR entries were inconsistent. The record also showed low BP, lethargy, poor intake, vomiting, diarrhea, and weight loss that were not consistently assessed or reported, with missing ordered lab results and no evidence of a cardiology follow-up being initiated.
Failure to Maintain Nutritional Status With Significant Weight Loss: A resident with CHF, COPD, moderate cognitive impairment, and malnutrition had poor PO intake, repeated meal documentation gaps, swallowing difficulty, and a marked weight decline from about 117 lb to 99 lb. Nursing notes described lethargy, flat affect, and poor appetite, while the provider note addressed chest pain and reflux but did not address the resident’s poor intake or weight loss; surveyors found no provider documentation addressing the nutritional decline.
A resident with CHF, COPD, lower back pain, depression, anxiety, and moderate cognitive impairment had frequent severe pain documented, including pain interfering with sleep and therapy. Staff repeatedly recorded pain scores up to 10/10 without consistently documenting pain location, characteristics, nonpharmacologic interventions, or provider notification, and ordered PRN pain medications were rarely or never administered. Chest pain and low blood pressure noted by therapy were not clearly assessed in nursing documentation, and the resident’s pain documentation was inconsistent across the MAR, TAR, and skilled notes.
A resident with dementia, gait impairment, weakness, and osteoporosis fell and complained of left hip pain. Staff ordered a hip x-ray, but it was not completed when expected, and the resident continued to have pain and difficulty moving the leg. The x-ray vendor said it was scheduled but had no time to come, and the resident was later sent to the hospital where a left hip fracture was diagnosed. The DON could not explain why the x-ray was not obtained or provide evidence of follow-up documentation.
Failure to follow hold parameters for Toprol XL: A resident with CHF, COPD, HTN, CAD, prior MI, and moderate cognitive impairment had an order for metoprolol to be held if HR was <60 or BP was <100/60. The MAR documented the medication as given even though the resident’s BP was 94/58, and the ADON agreed it was administered outside the ordered parameters.
Failure to Obtain Ordered BNP and TSH Labs: A resident with CHF, COPD, CAD, HTN, malnutrition, and moderate cognitive impairment had provider orders for a BNP to assess HF status and a TSH to monitor thyroid function while on Synthroid. When the ADON produced lab results, the BNP and TSH could not be found, and the ADON said she had even called the lab; the ordering provider later stated he did not remember the orders but suspected the BNP should have been completed if the other labs were done.
A resident's wound progress note and hospice consent were found uploaded into another resident's electronic chart during record review. The MRC said records are uploaded as soon as received when possible and that wrong records are deleted if placed in the wrong chart. The two residents had similar last names, and the facility's HIPPA Security Measures policy addressed protecting the confidentiality, integrity, and availability of resident records.
A resident with a DNR order and intact cognition experienced a sudden decline, including lethargy and labored breathing. Despite the resident's son requesting hospital transfer, staff did not initiate emergency transport or provide timely interventions, and the resident died hours later. Documentation and interviews revealed confusion among staff about the resident's care preferences, and the facility failed to follow its own policy for responding to significant changes in condition.
Facility staff did not ensure that medical provider orders entered by non-prescribing staff were signed by the prescribers, resulting in multiple unsigned orders for medications, therapies, and laboratory tests for several residents. The facility's policy requires timely provider signatures on all orders, but this was not consistently followed, as confirmed by record reviews and staff interviews.
Facility staff did not provide a resident's clinical record to an authorized representative within the required timeframe, despite documentation of a valid POA authorizing access. The request was denied due to the facility's insistence on additional proof of authority, even though the representative's rights were documented in the resident's records. The resident had expired and was previously assessed as cognitively intact.
Facility staff failed to promptly notify the provider after a resident with complex medical conditions experienced significant weight loss, with no documentation of provider notification at the time of the event. In a separate case, staff did not promptly inform a resident representative when another resident experienced a marked decline in condition, with notification occurring more than two hours after the initial symptoms were documented. Both incidents were contrary to facility policy requiring timely notification and documentation of significant changes in resident status.
A resident with intact cognition was admitted with a hospital discharge order for Prednisone on a tapering schedule for ulcerative pancolitis. Facility staff did not promptly order the medication upon admission, resulting in a missed dose on the second day. No documentation was found to explain the omission, despite facility policy requiring timely transcription and confirmation of admission medication orders.
Facility staff did not develop or implement baseline care plans within 48 hours of admission for three residents, including individuals with complex medical and mental health needs. Despite requests, the DON and leadership were unable to locate the required documentation, which is mandated by facility policy to ensure person-centered care upon admission.
Facility staff did not develop or implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, despite assessment findings indicating needs in areas such as pain management, incontinence, pressure ulcer risk, and therapy services. The care plan on record addressed only limited issues and omitted several critical areas identified in the assessment, with staff unable to provide a complete care plan when requested.
Facility staff did not provide a resident with ordered oxygen therapy at bedtime and failed to transcribe an order for a flutter valve breathing device following hospital discharge for acute respiratory failure with hypoxia. The resident did not receive the prescribed respiratory interventions, and staff documented administration of oxygen that was not actually provided.
Facility staff failed to ensure that a prescribed Narcan nasal spray, dispensed for a specific resident, was available when it was administered to another resident without proper documentation or replacement. The nurse practitioner obtained and administered the nasal spray from the medication cart, and staff could not identify the original recipient or provide evidence that the medication was replaced or the pharmacy notified.
Staff failed to maintain complete and accurate clinical records for a resident who experienced a decline and died. Documentation was missing or incomplete regarding Narcan administration, oxygen delivery, and vital signs, with some vital signs recorded at incorrect times. Progress notes from the nurse practitioner and Medical Director were either delayed or absent, despite involvement in care decisions.
Failure to Provide Standard Pain and Condition Monitoring
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality for one resident with multiple complex conditions, including acute on chronic CHF, COPD, muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression, and anxiety. The resident’s admission MDS showed moderate cognitive impairment, frequent pain that interfered with sleep, therapy, and daily activities, and pain as high as 9/10 over the prior five days. The resident also had poor functional status on admission, requiring substantial to maximal assistance with toileting, bathing, dressing, personal hygiene, bed mobility, and transfers, and was incontinent of bowel and bladder. The record showed repeated pain complaints and inconsistent pain assessment documentation. Skilled notes frequently documented pain levels as high as 10/10, but often did not include pain location, characteristics, or nonpharmacologic interventions. The TAR required pain assessment every shift and documentation of nonpharmacological interventions, yet the pain levels on the TAR did not consistently match the MAR or skilled notes, and some shifts had blank pain and intervention entries despite documented pain complaints. The resident also had complaints described as chest pain, stomach pain, rib pain, and back pain, but there was no corresponding nursing assessment in the record for some of those complaints. The MAR showed acetaminophen was ordered PRN but was administered only once during the stay, and nitroglycerin was ordered PRN for angina but was not administered at any point. The record also showed failure to adequately assess and respond to changes in condition, poor intake, and weight loss. Notes documented low blood pressure, lethargy, poor appetite, nausea, vomiting, diarrhea, and refusal of activity, but there was no evidence these findings were further assessed or reported to the provider in several instances. The resident lost weight during the stay, with the RD documenting a 5.2-pound loss in 9 days and poor appetite/PO intake, and the SLP documented ongoing challenges with oral intake and weight loss, including inability to effectively masticate or swallow oral trials. The provider had ordered BNP and TSH testing, but those results were not found in the record, and there was no evidence of a cardiology appointment being initiated despite a recommendation for follow-up. The resident later became unresponsive after vomiting and diarrhea and was sent emergently to the hospital, where the resident died a week later.
Failure to Maintain Nutritional Status With Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident admitted with acute on chronic CHF, COPD, muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, low back pain, depression, and anxiety. The resident’s admission weight was 115 to 117 pounds, and the admission MDS showed a BIMS score of 08, indicating moderate cognitive impairment. The record also showed a mechanical soft diet with thin liquids and a 2000 ml fluid restriction, while the resident reported poor appetite and disliked the mechanical soft texture. Documentation showed repeated low intake and missing meal documentation across multiple days, including no recorded lunch or breakfast/lunch entries on several dates, and several meals documented at 0-25% or 26-50% intake. Daily weights recorded a decline from 117.5 pounds to 112.2 pounds within days, then to 111.8 pounds and later to 99 pounds, reflecting a significant weight loss. The RD noted a 5.2-pound loss in 9 days, poor appetite, family bringing in foods, a reported usual body weight of 140 pounds before hospitalization, and a stage I pressure ulcer to the sacrum. Nursing and therapy notes documented lethargy, flat affect, poor appetite, sluggishness, and swallowing difficulty, but there was no evidence that alternatives were offered or that the medical provider was notified at those times. The provider progress note addressed chest pain, gas pain, and acid reflux worse after eating and drinking, but did not address poor intake or nutritional status. Speech therapy later documented ongoing nutritional risk, consistently low PO intake, weight loss, difficulty masticating or swallowing oral trials, and collaboration with nursing, dietician, and physician, while surveyors found no provider documentation addressing the resident’s weight loss or poor appetite.
Failure to Provide Complete Pain Assessment and Management
Penalty
Summary
The facility failed to provide pain management for a resident with multiple diagnoses including acute on chronic CHF, COPD, muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression, and anxiety. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 08, frequent pain that interfered with sleep, therapy participation, and day-to-day activities, and pain as high as 9/10 over the prior five days. The facility policy required pain to be recognized, assessed, and managed consistent with professional standards of practice, including evaluation of pain characteristics, nonverbal indicators, and the resident’s goals and preferences. Clinical records showed repeated documentation of severe pain without a complete assessment. Daily skilled notes frequently recorded pain levels as high as 10/10, but often did not include the pain location, characteristics, or nonpharmacologic interventions offered. The MAR showed acetaminophen ordered as needed for pain, but it was administered only once during the stay, and the resident had pain levels of 7 or higher on fifteen of seventeen days. The TAR also did not consistently match the pain levels documented in the MAR or skilled notes, and one shift had blank pain documentation despite pain being recorded elsewhere. The resident also reported chest pain and other pain complaints that were not consistently assessed or communicated. A PT note documented chest wall pain, stomach, rib, and back pain along with low blood pressure, but there was no nursing note showing assessment for chest pain or low blood pressure. A provider note later described chest pain as a burning epigastric sensation relieved with Tums and included Nitrostat PRN for angina, yet the MAR showed nitroglycerin was never administered. Several later skilled notes continued to document 10/10 pain without evidence that the high pain levels were assessed or reported to the medical provider. During interviews, the ADON and DON stated the resident did not have chest pain and relied on the skilled notes and MAR for pain assessment documentation.
Failure to Obtain Ordered X-Ray After Fall
Penalty
Summary
The facility failed to provide or obtain radiology services to meet the needs of a resident who sustained a left hip fracture after a fall. The resident had diagnoses including dementia with psychotic disturbance, lack of coordination, muscle weakness, gait and mobility abnormalities, and osteoporosis, and had severe cognitive impairment with frequent pain documented on the MDS. After a witnessed fall, the resident complained of left hip pain that worsened with movement and was rated 4 out of 10, and the provider ordered a left hip x-ray and PRN medication. Clinical documentation showed ongoing pain and difficulty moving the left leg, but the x-ray was not completed when expected. A nurse note documented that staff could not find x-ray results in the system and that the mobile x-ray company said the study was ordered for that day but had no time for completion. The nurse then notified the NP, who ordered the resident sent out because of the left hip pain. The resident was admitted to the hospital and diagnosed with a left hip fracture. Interviews with staff showed no clear explanation for why the x-ray was not obtained. An LPN stated the resident had complained of pain and that the x-ray was ordered, while another LPN said the resident was not someone who complained and that the resident had 10 out of 10 pain when the aide reported it. The DON stated she would expect the x-ray to be done the same day and acknowledged she had no explanation for the failure to obtain it and could not produce evidence of follow-up documentation or a physical assessment after the fall.
Failure to Follow Hold Parameters for Toprol XL
Penalty
Summary
Facility staff failed to follow a provider order for Resident #2’s Toprol XL (metoprolol) administration. The resident was admitted on 04/17/2025 and had a medical history that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, hypertension, coronary artery disease with a history of myocardial infarction, and moderate protein-calorie malnutrition. The admission MDS dated 04/23/2025 assigned a BIMS score of 8, indicating moderate cognitive impairment. The May 2025 MAR showed an order for Toprol XL 25 mg by mouth daily for hypertension with instructions to hold the medication if heart rate was less than 60, systolic blood pressure was less than 100, or diastolic blood pressure was less than 60. On 05/03/2025, the resident’s blood pressure was documented as 94/58, yet Toprol XL was documented as given despite both blood pressure parameters being outside the hold order. During the survey, the ADON reviewed the MAR and agreed the medication had been documented as given outside parameters.
Failure to Obtain Ordered BNP and TSH Labs
Penalty
Summary
The facility failed to obtain provider-ordered laboratory tests for one resident, including a BNP and a TSH level. The resident was admitted with a medical history that included acute on chronic congestive heart failure, COPD, hypertension, coronary artery disease with a history of myocardial infarction, and moderate protein-calorie malnutrition. The admission MDS assigned a BIMS score of 8, indicating moderate cognitive impairment. A history and physical note signed by the Medical Director ordered a BNP to assess the resident’s current heart failure status, along with CBC, CMP, and magnesium levels. A provider progress note later ordered a TSH level because the resident had a history of hyperthyroidism and was receiving Synthroid 50 mg daily. When the ADON provided lab results, the BNP and TSH could not be produced, and the ADON stated, "I even called the lab." The ordering provider later stated he did not remember the orders but suspected the BNP should have been done if the other labs were completed.
Incorrect Resident Records Uploaded to Wrong Chart
Penalty
Summary
Facility staff failed to maintain medical records in accordance with accepted professional standards for 1 of 8 residents reviewed, Resident #8. During a record review for Resident #4, surveyors observed a wound progress note dated 3/17/2026 and a hospice consent dated 3/16/26 for Resident #8 uploaded into Resident #4's electronic chart. The Medical Records Coordinator stated that records are uploaded as soon as they are received when possible, that she limits who uploads records to reduce mistakes, and that if a wrong record is uploaded into the wrong chart it is deleted immediately. It was also noted that Resident #8 had a similar last name to Resident #4. The facility later provided its HIPPA Security Measures policy, which stated that it is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of residents' identifiable information and/or records in electronic format.
Failure to Provide Timely Emergency Care and Honor Resident's Preferences Following Change in Condition
Penalty
Summary
Facility staff failed to appropriately respond to a significant decline in a resident's condition, which included symptoms such as lethargy, decreased responsiveness, clammy skin, and Cheyne-Stokes respirations. The resident, who had a DNR order but no other documented care limitations, was noted to have intact cognition and diagnoses including coronary artery disease, hypertension, and paroxysmal atrial fibrillation. Despite the resident's sudden decline, there was no evidence that staff checked the resident's blood sugar or initiated timely emergency transport. Clinical documentation showed that the nurse practitioner administered Narcan despite the resident refusing opioid medications, and applied oxygen for comfort, but did not document the amount or delivery device. Communication with the resident's son revealed that he requested hospital transfer after being informed of his father's condition, but there was no evidence that staff made any effort to arrange for transport. Staff interviews and progress notes indicated confusion regarding the resident's wishes, with some staff believing the son agreed to keep the resident at the facility, while the son stated he requested hospital transfer and did not agree to keep his father at the facility. The facility's own policy required prompt notification and emergency response in the event of a significant change in condition, including calling 911 and notifying the physician and resident representative. However, documentation and interviews confirmed that no emergency transport was initiated, and the resident died approximately four hours after the initial decline was documented. There was also a lack of timely and accurate documentation by the medical director and nurse practitioner regarding the resident's care preferences and actions taken.
Failure to Obtain Provider Signatures on Medical Orders
Penalty
Summary
Facility staff failed to ensure that medical provider orders were signed by the prescribing providers when orders were entered into residents' clinical records by non-prescribing staff. Clinical record reviews revealed multiple instances where orders, including those for medications, laboratory tests, and therapies, were not signed by the medical providers who issued them. The facility's own policy requires that both admission and routine orders be reviewed, signed, and dated by the prescribing provider as soon as practicable to maintain an accurate medical record. However, several orders for different residents, including those for barrier cream, CPAP therapy, dietary modifications, medications such as oxycodone and levofloxacin, and laboratory tests, remained unsigned by the respective prescribers. Interviews with the Medical Director confirmed that they had given orders throughout the year but could not specify the last time they had signed orders entered by facility staff. The Director of Nursing was made aware of the issue but had not yet determined the full extent of unsigned provider orders at the time of the survey. The deficiency was identified through interviews, clinical record reviews, and examination of facility documentation.
Failure to Timely Provide Resident Records to Authorized Representative
Penalty
Summary
Facility staff failed to provide a copy of a resident's clinical record to the resident's representative within the required two working days after a request was made. The request was made by the resident's representative, who was documented in the clinical record as holding a Durable General Power of Attorney (POA) with explicit authorization to request, receive, and review the resident's medical and hospital records. Despite this documentation, the facility declined the request, citing a lack of supporting documentation to prove authority to access the records on the resident's behalf. The facility's documentation showed that the request was forwarded to the legal department, and a denial letter was sent to the representative, stating the request was incomplete due to missing proof of authority. An email from the Administrator reiterated the denial, specifying that proof of authority, such as a death certificate and identification, was required. The resident in question had expired while at the facility and was assessed as cognitively intact or borderline, with a BIMS score of 14 out of 15. The facility's own policy defined a personal representative as someone authorized under state or applicable law to act on behalf of the individual in making health care decisions and to exercise the individual's rights.
Failure to Promptly Notify Provider and Resident Representative of Significant Change in Condition
Penalty
Summary
Facility staff failed to promptly notify the medical provider after a resident with multiple complex medical diagnoses, including gastrointestinal disorders and diabetes, experienced a significant weight loss. The resident's weight dropped from 161.0 lbs to 139.2 lbs over a period of less than two months, which was identified as a nutritionally significant loss by the dietician. Despite this, there was no documentation that the provider was notified of the weight loss at the time it was first recorded, and the only related note was from the dietician nearly a month later. The Director of Nursing confirmed that no evidence of provider notification was found for the date of the significant weight loss. In a separate incident, staff did not promptly notify a resident representative when another resident experienced a notable decline in condition. The resident, who was assessed as cognitively intact, was documented as having increased somnolence, lethargy, clammy skin, swallowing problems, and shallow respirations over the course of several hours. Although the nurse practitioner was notified of some changes, there was no documentation that the resident representative was informed of the decline until more than two hours after the initial assessment of increased somnolence and other symptoms. Facility policy required prompt notification of the attending physician and resident representative in the event of significant changes in a resident's physical, mental, or psychosocial status, and for such notifications to be documented in the medical record. In both cases, the required notifications were either delayed or not documented, resulting in a failure to follow established procedures for changes in resident condition.
Failure to Timely Continue Hospital-Ordered Medication at Admission
Penalty
Summary
Facility staff failed to ensure that a medication ordered to be continued after hospital discharge was promptly ordered upon admission for a resident. Specifically, Prednisone, which was prescribed on a tapering schedule for ulcerative pancolitis with complications, was not ordered until the resident's second day at the facility. As a result, the resident missed a scheduled dose of Prednisone on their second day. There was no documentation provided or found to explain why this medication was not included in the admission medication orders. The resident was assessed as having intact or borderline cognition, with a BIMS score of 14 out of 15, and was able to make themselves understood and understand others. The hospital discharge summary clearly indicated the need for Prednisone to be continued, and the facility's policy required that physician orders be reviewed, verified, and transcribed to the medical record upon admission. Despite this, the order for Prednisone was not written until the second day, to be started on the third day, resulting in a missed dose.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by facility policy. For one resident with multiple complex diagnoses including sepsis, diabetes, sleep apnea, anxiety, depression, dementia, and COVID-19, no baseline care plan was found in the clinical record. This resident was also noted to have severe cognitive impairment, incontinence, a colostomy, pressure ulcers, surgical wounds, and was on isolation. Despite requests, the Director of Nursing (DON) was unable to provide the baseline care plan, stating that such plans were kept on paper by unit managers but could not be located. Similarly, another resident with diagnoses including schizophrenia, depression, diabetes, COVID-19, hypertension, and colon cancer, and who was at risk for pressure ulcers and had a surgical wound, also did not have a baseline care plan in the record. This resident experienced frequent pain and was on multiple medications, including opioids, antipsychotics, antidepressants, and diuretics. A third resident, assessed as having intact or borderline cognition, also lacked a baseline care plan in their clinical record. In all cases, the DON and facility leadership confirmed that the required baseline care plans could not be found, despite the facility's policy mandating their development and implementation within 48 hours of admission.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for one resident. The resident had multiple diagnoses, including a right hip fracture with surgical repair, protein calorie malnutrition, diabetes, chronic kidney disease, anemia, breast cancer, and hypertension. The Minimum Data Set (MDS) assessment indicated mild cognitive impairment, frequent incontinence, severe pain interfering with daily activities, insulin injections, risk for pressure ulcers, a surgical wound, and ongoing therapy services. The Care Area Assessment (CAA) worksheets identified the need for care plans addressing vision, communication, functional abilities, urinary incontinence, falls, pressure ulcers/injury, and pain. Upon review, the resident's care plan only included focuses for COVID-19, activities, discharge planning, nutrition, and do not resuscitate orders, with no evidence of care plans for the other identified needs. When asked, the Director of Nursing was unable to provide a comprehensive care plan and acknowledged a miscommunication regarding responsibility for care plan development. The facility's policy requires an individualized, person-centered plan of care developed by the interdisciplinary team, but this was not followed for the resident in question.
Failure to Provide Ordered Respiratory Care and Oxygen Therapy
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident with a diagnosis of acute respiratory failure with hypoxia. The resident had a physician's order for oxygen at 2 liters via nasal cannula at bedtime for shortness of breath, as well as a hospital discharge summary indicating the need for continued use of a flutter valve breathing device after discharge. However, the order for the flutter valve was not transcribed into the resident's physician order summary, and the resident reported not having the device since leaving the hospital. Staff interviews confirmed that the resident was not using a flutter valve. Additionally, although the resident's baseline care plan and physician's order summary included an order for oxygen at bedtime, there was no oxygen concentrator observed in the resident's room, and both the resident and staff confirmed that oxygen had not been used since admission from the hospital. Despite this, the electronic treatment administration record showed that staff had been initialing oxygen as being administered per the physician's order. These findings were discussed with facility leadership, but no further information was provided prior to the survey exit.
Failure to Ensure Availability and Proper Administration of Prescribed Medication
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available to meet residents' needs when a Narcan nasal spray, dispensed by the pharmacy for a specific resident, was administered to another resident without proper documentation or replacement. The nurse practitioner administered two doses of Narcan nasal spray to a resident who did not have an order for it, and the staff could not identify which resident's medication was used. The Narcan nasal spray was not part of the facility's as-needed medication stock, which only included injectable Narcan, indicating that the nasal spray had been specifically dispensed for an individual resident. Interviews with staff revealed that the nurse practitioner obtained the Narcan nasal spray directly from the medication cart, and the staff were unable to provide evidence that the pharmacy was notified or that the medication was replaced for the intended resident. The Director of Nursing confirmed the lack of documentation and inability to identify the original recipient of the Narcan nasal spray, resulting in a failure to ensure the medication's availability for the resident it was prescribed to.
Incomplete and Inaccurate Clinical Record Documentation for Resident at Time of Decline and Death
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for one of nine sampled residents. The resident was assessed as having intact or borderline cognition and was able to communicate effectively. On the day of the resident's decline and subsequent death, documentation was incomplete and inaccurate: a nurse's note indicated administration of two doses of Narcan without specifying the route, the oxygen device, or the amount administered. Vital signs were documented at a time when they were not actually obtained, and the nurse confirmed that the recorded time was incorrect. Additionally, the clinical record lacked progress notes from the nurse practitioner or physician for the day of the resident's decline and death. Further review revealed that the nurse practitioner’s note was not provided until the afternoon of the following day and did not include times for when certain vital signs were obtained. The note also contained a respiratory rate documented after the resident's recorded time of death. The facility's policy required accurate and timely documentation of procedures and resident responses, which was not followed. The absence of a progress note from the Medical Director for the day in question was also noted, despite the Medical Director reporting involvement in care decisions and attempted communication with the resident's family.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roanoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Roanoke Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center - South | 1.9 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Raleigh Court Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
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