Cycle 1
Health 2024-10-29 · Fire 2024-10-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Roanoke, VA
Friendship Health And Rehab Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
327 Hershberger Rd Nw, Roanoke, VA
(540) 265-2100
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
253
Certified beds
Average residents
232
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing
LPN hours / resident day
1.23
Licensed practical nurse staffing
Aide hours / resident day
2.22
Nurse aide staffing
Weekend hours
3.09
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
91.2%
0.2 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
94.0%
1 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
15.7%
13.2 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.7%
1 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
20.2%
7.7 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
15.0%
6.6 pts worse
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.8% |
17.5%
3.3 pts worse
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
15.7%
2.3 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.6%
0.7 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
22.2%
3.7 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.2%
0.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
74.6%
17.5 pts better
|
81.7%
10.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
11.7%
0.6 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
73.6%
12.6 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
22.0%
5.3 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-10 · Fire 2022-03-10
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-06-17 · Fire 2021-06-17
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-29
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-03-12
E · Potential for more than minimal harm
2022-03-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-03-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-03-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-03-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-03-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-03-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-27
F · Potential for more than minimal harm
2021-06-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-08-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-29
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 2024-12-11
D · Potential for more than minimal harm
2024-10-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-12-11
D · Potential for more than minimal harm
2023-03-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-04
D · Potential for more than minimal harm
2022-03-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-04-20
D · Potential for more than minimal harm
2022-03-10
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 2022-04-20
D · Potential for more than minimal harm
2022-03-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-04-20
D · Potential for more than minimal harm
2022-03-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-04-20
D · Potential for more than minimal harm
2022-03-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-04-20
D · Potential for more than minimal harm
2021-06-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-28
D · Potential for more than minimal harm
2021-06-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-07-28
D · Potential for more than minimal harm
2021-06-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-07-28
D · Potential for more than minimal harm
2021-06-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-28
D · Potential for more than minimal harm
2021-06-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-28
D · Potential for more than minimal harm
2021-06-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-28
D · Potential for more than minimal harm
2021-06-17
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 2021-07-28
Penalties and ownership
What sits behind the stars
Ownership
Bishop, Nathaniel
Corporate Director · Individual
Combs, Glen
Corporate Director · Individual
Feinour, Edwin
Corporate Director · Individual
Friendship Foundation Inc
Operational/Managerial Control · Organization
Grove, Lucian
Corporate Director · Individual
Hoff, Joseph
Corporate Officer · Individual
Johnson, Cynda
Corporate Director · Individual
Lawson, Robert
Corporate Director · Individual
Mitchell, Cynthia
Corporate Officer · Individual
Oelschlager, Kathryn
Corporate Director · Individual
Sandel, Robert
Corporate Director · Individual
Shannon, Charles
Operational/Managerial Control · Individual
Shannon, Charles
Corporate Officer · Individual
Williamson, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Star City Rehabilitation And Nursing
Roanoke, VA
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Our Lady Of The Valley
Roanoke, VA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Springtree Healthcare & Rehab Center
Roanoke, VA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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