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
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
1.36
Licensed practical nurse staffing
Aide hours / resident day
2.24
Nurse aide staffing
Weekend hours
3.49
Weekend nurse staffing
RN turnover
39%
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 | 1.6 |
1.5
0.1 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 10.4% |
17.5%
7.1 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 | 14.2% |
22.2%
8 pts better
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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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