Pheasant Ridge Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pheasant Ridge Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jul 28, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the medical provider of a significant change in condition in a timely manner for two (2) of 51 residents in the survey sample, Resident #95 and Resident #6.The facility's failure to recognize, act upon, and report a heart rate of 131 beats per minute to a medical provider for approximately six hours, likely caused and/or hastened the resident's death which occurred one to two hours after being sent out to the hospital with complaints of shortness of breath and chest pain.This resulted in the identification of Immediate Jeopardy for Resident #95. The survey team informed the facility on [DATE] at 3:28 PM of the Immediate Jeopardy situation regarding Resident #95. […]

• Immediate jeopardy, isolatedF760Jul 28, 2026

  Based on family interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 6 of 51 sampled residents, Resident #94, Resident #2, Resident #33, Resident #95, Resident #29, and Resident #43. For Resident #94, the facility staff failed to remove the anticoagulant, Eliquis from the resident's active medication supply when discontinued on [DATE]. 12 Eliquis tablets were missing from Resident #94's Eliquis supply and were unaccounted for. Lab results obtained on [DATE] revealed a critically low hemoglobin of 6.7, a low hematocrit of 20.9, and PT/INR levels that were unable to be determined due to no clotting endpoint on the lab instrument. […]

• Immediate jeopardy, isolatedF770Jul 28, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain lab testing as ordered by the medical provider for 8 of 51 sampled residents, Resident #94, Resident #2, Resident #3, Resident #5, Resident #7, Resident #8, Resident #12, and Resident #6. For Resident #94, the facility staff failed to obtain PT/INR results as ordered following the transition of Eliquis to Coumadin using a limited Lovenox bridge on four separate occasions from [DATE] through [DATE]. Lab results obtained on [DATE] and received by the lab on [DATE] resulted in a PT greater than 90 (reference range 9.60-11.33) and INR results that could not be calculated as the result greater than linearity. Resident #94 began showing signs of active bleeding on [DATE]. […]

• Immediate jeopardy, isolatedF684Nov 21, 2024

  Based on interviews, clinical record review, and facility document review, the facility staff failed to appropriately respond to a decline/change in condition (lethargy, oriented to person only, clammy skin, Cheyne-Stokes labored irregular breathing) for one 1 of nine 9 sampled residents (Resident #9), resulting in death. The scope and severity was originally cited at Immediate Jeopardy, Level IV isolated, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The Administrator, Director of Nursing (DON), and Quality Assurance (QA) Nurse were notified on [DATE] at 1:45 p.m. that the survey team had identified Immediate Jeopardy in the area of Quality of Care. […]

• Actual harm, isolatedF600Jul 28, 2026

  Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to protect the resident's right to be free from sexual abuse and physical abuse by another resident of the facility for 1 of 39 current sampled residents, Resident #69. The facility staff failed to (1) protect Resident #69 from sexual abuse by another resident (Resident #98) on 4/15/26 and (2) protect Resident #69 from physical abuse resulting from an altercation with another resident (Resident #64) on 7/04/26. The facility's investigation determined that the altercation on 7/04/26 resulted in a closed fracture of the right fourth metatarsal neck thus constituting harm to Resident #69. […]