Cycle 1
Health 2023-08-25 · Fire 2023-08-25
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Roanoke, VA
Our Lady Of The Valley
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
650 North Jefferson Street, Roanoke, VA
(540) 345-5111
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,807
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.06
Baseline 19.61% · Performance 20.48% · Measure score 2.06 · Achievement 2.06 · Improvement 0
Healthcare-associated infections
5.04
Baseline 6.17% · Performance 6.33% · Measure score 5.04 · Achievement 5.04 · Improvement 0
Total nurse turnover
6.08
Baseline 72.58% · Performance 41.18% · Measure score 6.08 · Achievement 5.51 · Improvement 6.08
Adjusted total nurse staffing
3.87
Baseline 3.30 hours · Performance 4.18 hours · Measure score 3.87 · Achievement 3.87 · Improvement 3.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.07% |
10.72%
4.3 pts worse
|
Worse than the National Rate · Eligible stays 278 · Observed rate 16.91% · Lower 95% interval 11.69% |
| Discharge to community | 63.16% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 251 · Observed rate 60.16% · Lower 95% interval 57.45% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.3% |
95.27%
4 pts better
|
Numerator 142 · Denominator 143 |
| Falls with major injury | 0.7% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 143 |
| Discharge self-care score | 70.69% |
53.69%
17 pts better
|
Numerator 82 · Denominator 116 |
| Discharge mobility score | 74.14% |
50.94%
23.2 pts better
|
Numerator 86 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 0.7% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 143 · Adjusted rate 0.74% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 4.32% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 6.84% |
8.2%
1.4 pts worse
|
Numerator 8 · Denominator 117 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 73.28% |
56.45%
16.8 pts better
|
Numerator 85 · Denominator 116 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 96 · Denominator 96 |
| Resident COVID-19 vaccinations up to date | 48.15% |
25.2%
22.9 pts better
|
Numerator 39 · Denominator 81 |
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 1.0 · Expected 1.3 · 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 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
3.6%
3.7 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 8.2% · Q3 8.5% · Q4 7.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 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 who lose too much weight | 2.9% |
5.7%
2.8 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
20.2%
1.9 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 19.4% · Q3 18.4% · Q4 31.2% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
15.0%
11.4 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.6% · Q3 3.3% · Q4 4.2% · 4Q avg 3.6% · 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 | 23.5% |
17.5%
6 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
15.7%
4.4 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 6.1% · Q3 31.4% · Q4 13.3% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.6%
0.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
22.2%
4.5 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 35.6% · Q3 22.4% · Q4 37.6% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.8% · Q3 1.8% · Q4 3.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
74.6%
25 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.1% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.7%
1.1 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 9.4% · Expected 9.9% · 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 1.6% · Q2 1.2% · Q3 0.0% · Q4 1.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
73.6%
22.8 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
22.0%
4.6 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 21.5% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-15 · Fire 2021-04-15
5 health deficiencies
Top issue: Administration (1 deficiency)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2019-04-08 · Fire 2019-04-08
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-28
D · Potential for more than minimal harm
2023-08-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-28
F · Potential for more than minimal harm
2021-04-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-15
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 2021-06-15
E · Potential for more than minimal harm
2021-04-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-15
C · Minimal harm
2021-04-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-05-25
C · Minimal harm
2021-04-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-05-25
C · Minimal harm
2021-04-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-05-25
C · Minimal harm
2021-04-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-05-25
C · Minimal harm
2021-04-15
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-05-25
C · Minimal harm
2021-04-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-05-25
F · Potential for more than minimal harm
2019-04-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-06-20
F · Potential for more than minimal harm
2019-04-08
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-06-20
F · Potential for more than minimal harm
2019-04-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-20
F · Potential for more than minimal harm
2019-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-20
F · Potential for more than minimal harm
2019-04-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-08-25
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 2023-10-24
D · Potential for more than minimal harm
2023-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-08-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-08-25
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 2023-10-24
F · Potential for more than minimal harm
2021-04-15
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 2021-05-25
D · Potential for more than minimal harm
2021-04-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-25
D · Potential for more than minimal harm
2021-04-15
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 2021-05-25
D · Potential for more than minimal harm
2021-04-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-25
C · Minimal harm
2021-04-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-05-25
F · Potential for more than minimal harm
2019-04-08
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 2019-05-17
D · Potential for more than minimal harm
2019-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-04-08
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 2019-05-17
D · Potential for more than minimal harm
2019-04-08
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 2019-05-17
Penalties and ownership
What sits behind the stars
Ownership
Catrambone, Joseph
Operational/Managerial Control · Individual
Mcnichols, Mary
W-2 Managing Employee · Individual
Rawlings, David
Operational/Managerial Control · Individual
Rawlings, David
Corporate Director · Individual
Staples, Emily
Operational/Managerial Control · Individual
Staples, Emily
Corporate Director · Individual
White, Denise
Operational/Managerial Control · Individual
White, Denise
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Old Southwest Health And Rehabilitation
Roanoke, VA
1-star overall rating with 1-star inspections with $143,823 in total fines with 46 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Raleigh Court Health And Rehabilitation Center
Roanoke, VA
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
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
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