Cycle 1
Health 2024-04-25 · Fire 2024-04-25
13 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Roanoke, VA
Friendship Health And Rehab Center - South
3-star overall rating with 3-star inspections with $8,281 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5647 Starkey Road, Roanoke, VA
(540) 265-2117
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-05-16
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
0.57
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.49
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
39%
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
6,565
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.40% · Performance 24.24% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.62
Baseline 4.46% · Performance 7.05% · Measure score 2.62 · Achievement 2.62 · Improvement 0
Total nurse turnover
5.87
Baseline 53.38% · Performance 39.68% · Measure score 5.87 · Achievement 5.87 · Improvement 4.30
Adjusted total nurse staffing
4.49
Baseline 4.17 hours · Performance 4.35 hours · Measure score 4.49 · Achievement 4.49 · Improvement 0.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 570 · Observed rate 8.77% · Lower 95% interval 8.14% |
| Discharge to community | 66.89% |
50.57%
16.3 pts better
|
Better than the National Rate · Eligible stays 579 · Observed rate 64.77% · Lower 95% interval 63.55% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 371 · Denominator 371 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 371 |
| Discharge self-care score | 55.79% |
53.69%
2.1 pts better
|
Numerator 159 · Denominator 285 |
| Discharge mobility score | 52.63% |
50.94%
1.7 pts better
|
Numerator 150 · Denominator 285 |
| Pressure ulcers or injuries, new or worsened | 1.08% |
2.29%
1.2 pts better
|
Numerator 4 · Denominator 371 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 384 · Observed rate 5.73% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 1.55% |
8.2%
6.6 pts worse
|
Numerator 3 · Denominator 194 |
| Staff flu vaccination coverage | 35.42% |
42%
6.6 pts worse
|
Numerator 96 · Denominator 271 |
| Discharge function score | 45.96% |
56.45%
10.5 pts worse
|
Numerator 131 · Denominator 285 |
| Transfer of health information to provider | 67.05% |
95.95%
28.9 pts worse
|
Numerator 59 · Denominator 88 |
| Transfer of health information to patient | 91.25% |
96.28%
5 pts worse
|
Numerator 219 · Denominator 240 |
| 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 | 1.6 |
1.5
0.1 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.4
About the same
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
94.0%
2.6 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.6%
1.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 2.5% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
15.7%
12.7 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.4% · Q4 8.3% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.7%
3.5 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.6% · Q3 1.4% · Q4 1.4% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
20.2%
5.8 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 26.7% · Q3 24.4% · Q4 22.0% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
15.0%
0.3 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 13.1% · Q3 10.6% · Q4 15.1% · 4Q avg 15.3% · 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 | 10.4% |
17.5%
7.1 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 12.2% · Q3 7.1% · Q4 14.9% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
15.7%
1.2 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.1% · Q3 9.2% · Q4 17.1% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.7% · 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 1.3% · Q2 1.3% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.2% |
22.2%
8 pts better
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 10.4% · Q3 11.4% · Q4 9.8% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.2%
0.7 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 1.4% · Q3 8.3% · Q4 7.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
74.6%
22.1 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 96.3% · Q3 98.5% · Q4 99.2% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
11.7%
2.5 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 12.2% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.2%
0.7 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.7% · Q3 1.1% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
73.6%
21.8 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
22.0%
0.4 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 17.0% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-05 · Fire 2019-12-05
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-21
B · Minimal harm
2024-04-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-21
F · Potential for more than minimal harm
2022-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-10-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-10-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-10-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-10-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-10-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-10-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-05
F · Potential for more than minimal harm
2019-12-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-01-23
D · Potential for more than minimal harm
2019-12-05
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2020-01-23
D · Potential for more than minimal harm
2019-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-23
Inspection history
Recent health citations
J · Immediate jeopardy
2025-06-18
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 2025-01-29
D · Potential for more than minimal harm
2025-06-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-04-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
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 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
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 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-04-25
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-06-20
E · Potential for more than minimal harm
2022-10-13
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 2022-11-15
D · Potential for more than minimal harm
2022-10-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-15
D · Potential for more than minimal harm
2019-12-05
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 2019-12-13
D · Potential for more than minimal harm
2019-12-05
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 2019-12-13
Penalties and ownership
What sits behind the stars
$8,281
2025-06-18
Fine
Fine · fine $8,281
Fine
Ownership
Friendship Foundation Inc
5% Or Greater Direct Ownership Interest · Organization
Bishop, Nathaniel
Corporate Director · Individual
Combs, Glen
Corporate Director · Individual
Evans, Brandon
W-2 Managing Employee · Individual
Feinour, Edwin
Corporate Director · Individual
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
Corporate Officer · Individual
Williamson, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Pheasant Ridge Nursing and Rehabilitation
Roanoke, VA
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
South Roanoke Nursing And Rehabilitation
Roanoke, VA
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Raleigh Court Health And Rehabilitation Center
Roanoke, VA
3-star overall rating with 3-star inspections with 7 recent health deficiencies
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