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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,456
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.93% · Performance 22.91% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.71% · Performance 8.03% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.67
Baseline 52.06% · Performance 44.58% · Measure score 4.67 · Achievement 4.67 · Improvement 2.25
Adjusted total nurse staffing
4.77
Baseline 3.77 hours · Performance 4.43 hours · Measure score 4.77 · Achievement 4.77 · Improvement 2.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 456 · Observed rate 10.31% · Lower 95% interval 8.02% |
| Discharge to community | 61.57% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 473 · Observed rate 54.97% · Lower 95% interval 56.63% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.18% |
95.27%
3.9 pts better
|
Numerator 361 · Denominator 364 |
| Falls with major injury | 0.55% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 364 |
| Discharge self-care score | 48.51% |
53.69%
5.2 pts worse
|
Numerator 130 · Denominator 268 |
| Discharge mobility score | 39.93% |
50.94%
11 pts worse
|
Numerator 107 · Denominator 268 |
| Pressure ulcers or injuries, new or worsened | 3.02% |
2.29%
0.7 pts worse
|
Numerator 11 · Denominator 364 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 8.03% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 319 · Observed rate 7.84% · Lower 95% interval 6.07% |
| Staff COVID-19 vaccination coverage | 1.47% |
8.2%
6.7 pts worse
|
Numerator 6 · Denominator 407 |
| Staff flu vaccination coverage | 32.66% |
42%
9.3 pts worse
|
Numerator 145 · Denominator 444 |
| Discharge function score | 42.16% |
56.45%
14.3 pts worse
|
Numerator 113 · Denominator 268 |
| Transfer of health information to provider | 98.44% |
95.95%
2.5 pts better
|
Numerator 252 · Denominator 256 |
| Transfer of health information to patient | 72.22% |
96.28%
24.1 pts worse
|
Numerator 39 · Denominator 54 |
| Resident COVID-19 vaccinations up to date | 20.21% |
25.2%
5 pts worse
|
Numerator 38 · Denominator 188 |
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 · Adjusted 1.5 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 92.1% · Q2 86.6% · Q3 90.6% · Q4 94.5% · 4Q avg 91.0% |
| 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 · 4Q avg 93.0% |
| 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 · Q1 7.3% · Q2 4.8% · Q3 3.9% · Q4 4.5% · 4Q avg 5.1% · Used in QM five-star |
| 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 · Q1 1.7% · Q2 0.6% · Q3 1.8% · Q4 5.9% · 4Q avg 2.5% |
| 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 · Q1 6.7% · Q2 11.4% · Q3 5.2% · Q4 3.7% · 4Q avg 6.7% |
| 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 · Q1 12.2% · Q2 10.7% · Q3 12.7% · Q4 14.2% · 4Q avg 12.5% |
| 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 · Q1 22.4% · Q2 21.8% · Q3 20.8% · Q4 21.6% · 4Q avg 21.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 29.2% · Q2 17.5% · Q3 13.6% · Q4 22.8% · 4Q avg 20.8% · Used in QM five-star |
| 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 · Q1 21.6% · Q2 14.2% · Q3 13.1% · Q4 22.8% · 4Q avg 18.0% · Used in QM five-star |
| 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 · Q1 1.0% · Q2 1.3% · Q3 0.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| 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 · Q1 1.0% · Q2 1.1% · Q3 1.1% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 28.4% · Q2 23.0% · Q3 22.9% · Q4 29.0% · 4Q avg 25.9% |
| 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 · Q1 4.8% · Q2 8.2% · Q3 6.3% · Q4 4.1% · 4Q avg 5.8% · Used in QM five-star |
| 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 · Q1 91.3% · Q2 88.2% · Q3 93.2% · Q4 95.8% · 4Q avg 92.1% |
| 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 · Adjusted 12.3% · Observed 11.4% · Expected 10.4% · Used in QM five-star |
| 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 · Q1 0.4% · Q2 0.0% · Q3 1.6% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star |
| 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 · 4Q avg 86.2% |
| 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 · Adjusted 27.3% · Observed 25.2% · Expected 22.1% · Used in QM five-star |
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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