Federal inspection record · CMS data as of October 1, 2026
Friendship Health And Rehab Center - South
5647 Starkey Road, Roanoke, VA · (540) 777-8300
- Certified beds
- 120
- Residents per day
- 113
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 16, 2016
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Virginia.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Virginia homes
Friendship Health And Rehab Center - South carries 47 inspection points. That is fewer than 63% of Virginia's 287 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Virginia: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–16 pts
- 4★ 16–45 pts
- 3★ 45–76.5 pts
- 2★ 76.5–168.75 pts
- 1★ over 168.75 pts
Bars show every rated home in Virginia by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
19 health citations on record since 2019. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
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J
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.
Everything else, by area of care
Pharmacy Service7E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
Ensure that residents are free from significant medication errors.
- E
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.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
Resident Assessment and Care Planning4D
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control4D
- D
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
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.
- D
Provide and implement an infection prevention and control program.
Quality of Life and Care2D
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Resident Rights1D
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspection history
2024-04-25
11 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2022-10-13
5 health deficiencies · 10 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2019-12-05
3 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 15 min of nursing staff time a day, 39 min of it from a registered nurse.
This home
4 h 15 min
Virginia average
3 h 53 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 45% of nursing staff and 27% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$8,281 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-06-18 | Fine | $8,281 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts worse | 1.7 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.4 pts better | 1.0 | 1.4 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine8.8 pts better | 100.0% | 91.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine6.7 pts better | 100.0% | 93.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.4 pts better | 2.1% | 3.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.9 pts better | 15.6% | 20.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.4 pts better | 2.9% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.6 pts better | 20.1% | 20.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.7 pts worse | 16.9% | 14.2% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened2.1 pts better | 12.1% | 14.2% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.3 pts worse | 16.8% | 14.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.2 pts better | 0.2% | 0.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.3 pts better | 0.3% | 1.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence8.5 pts better | 12.8% | 21.3% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2 pts worse | 6.4% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine25.5 pts better | 99.7% | 74.2% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.8 pts better | 10.7% | 11.5% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.3 pts better | 0.0% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine25.9 pts better | 99.2% | 73.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.5 pts worse | 25.5% | 22.0% | 23.4% |
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Who owns and runs it
14 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Friendship Foundation Inc | 5% Or Greater Direct Ownership Interest · Organization | 100% | 3 facilities |
| Bishop, Nathaniel | Corporate Director · Individual | 0% | 3 facilities |
| Combs, Glen | Corporate Director · Individual | 0% | 3 facilities |
| Evans, Brandon | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Feinour, Edwin | Corporate Director · Individual | 0% | 3 facilities |
| Grove, Lucian | Corporate Director · Individual | 0% | 3 facilities |
| Hoff, Joseph | Corporate Officer · Individual | 0% | 3 facilities |
| Johnson, Cynda | Corporate Director · Individual | 0% | 3 facilities |
| Lawson, Robert | Corporate Director · Individual | 0% | 3 facilities |
| Mitchell, Cynthia | Corporate Officer · Individual | 0% | 3 facilities |
| Oelschlager, Kathryn | Corporate Director · Individual | 0% | 3 facilities |
| Sandel, Robert | Corporate Director · Individual | 0% | 3 facilities |
| Shannon, Charles | Corporate Officer · Individual | 0% | 3 facilities |
| Williamson, John | Corporate Director · Individual | 0% | 3 facilities |
·
Fire safety
17 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke7F
- D
Inspect, test, and maintain automatic sprinkler systems.
- B
Install an approved automatic sprinkler system.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems3F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- E
Have generator or other power source capable of supplying service within 10 seconds.
- E
Meet requirements for the installation and maintenance of electrical systems.
Egress3F
- D
Have properly located and lighted "Exit" signs.
- F
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.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Miscellaneous2F
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have simulated fire drills held at unexpected times.
Services2E
- E
Have properly installed electrical wiring and gas equipment.
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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Other homes nearby
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Pheasant Ridge Nursing and Rehabilitation
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★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
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- Fines
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South Roanoke Nursing And Rehabilitation
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- Nursing / resident / day
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-
Raleigh Court Health And Rehabilitation Center
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- Nursing / resident / day
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