Cycle 1
Health 2024-08-15 · Fire 2024-08-15
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Roanoke, VA
Raleigh Court Health And Rehabilitation Center
3-star overall rating with 3-star inspections with 7 recent health deficiencies
1527 Grandin Road Southwest, Roanoke, VA
(540) 342-9525
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1990-04-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
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
0.53
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.95
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.62% · Performance 21.39% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.90% · Performance 9.24% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 71.43% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.67 hours · Performance 2.70 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 11.45% · Lower 95% interval 8.08% |
| Discharge to community | 47.85% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 42.14% · Lower 95% interval 40.02% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 95 · Denominator 95 |
| Falls with major injury | 1.05% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 95 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 36 · Denominator 63 |
| Discharge mobility score | 73.02% |
50.94%
22.1 pts better
|
Numerator 46 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 94 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.24% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 13.33% · Lower 95% interval 5.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 11.54% |
42%
30.5 pts worse
|
Numerator 18 · Denominator 156 |
| Discharge function score | 68.25% |
56.45%
11.8 pts better
|
Numerator 43 · Denominator 63 |
| Transfer of health information to provider | 97.37% |
95.95%
1.4 pts better
|
Numerator 37 · Denominator 38 |
| Transfer of health information to patient | 88.1% |
96.28%
8.2 pts worse
|
Numerator 37 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 32.14% |
25.2%
6.9 pts better
|
Numerator 18 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
91.2%
7.4 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 97.9% · Q3 100.0% · Q4 98.8% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.0%
5 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.6%
1.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.4% · Q4 4.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 78.4% |
15.7%
62.7 pts worse
|
11.4%
67 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 73.9% · Q3 77.2% · Q4 80.2% · 4Q avg 78.4% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.7%
3.3 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.4% · Q3 1.3% · Q4 1.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
20.2%
0.6 pts better
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 25.3% · Q3 19.2% · Q4 16.2% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
15.0%
3.5 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 11.8% · Q3 9.7% · Q4 15.1% · 4Q avg 11.5% · 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 | 14.1% |
17.5%
3.4 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 10.8% · Q3 7.8% · Q4 25.3% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
15.7%
1.9 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 9.2% · Q3 12.0% · Q4 18.7% · 4Q avg 17.6% · 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 | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 28.7% |
22.2%
6.5 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 20.1% · Q3 30.7% · Q4 34.8% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.2%
3.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.8% · Q3 2.1% · Q4 3.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
74.6%
13.6 pts better
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 78.5% · Q3 86.0% · Q4 94.1% · 4Q avg 88.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
11.7%
6.9 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.3% · Expected 10.1% · 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 0.0% · Q2 0.0% · Q3 0.9% · Q4 2.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
73.6%
11 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
22.0%
5.4 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.1% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-19 · Fire 2022-12-19
21 health deficiencies
Top issue: Resident Rights (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-03
F · Potential for more than minimal harm
2022-12-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-03
F · Potential for more than minimal harm
2022-12-19
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 2023-06-12
E · Potential for more than minimal harm
2022-12-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-12
E · Potential for more than minimal harm
2022-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-03
E · Potential for more than minimal harm
2022-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-03
E · Potential for more than minimal harm
2022-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-03
D · Potential for more than minimal harm
2022-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-03
D · Potential for more than minimal harm
2022-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
E · Potential for more than minimal harm
2020-03-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-03-12
E · Potential for more than minimal harm
2020-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-03-12
E · Potential for more than minimal harm
2020-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-03-12
E · Potential for more than minimal harm
2020-03-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-03-12
E · Potential for more than minimal harm
2020-03-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-03-12
D · Potential for more than minimal harm
2020-03-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-03-12
D · Potential for more than minimal harm
2020-03-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-03-12
D · Potential for more than minimal harm
2020-03-12
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-03-12
D · Potential for more than minimal harm
2020-03-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-03-12
D · Potential for more than minimal harm
2020-03-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-03-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-15
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 2024-10-10
D · Potential for more than minimal harm
2024-08-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-15
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 2024-10-10
D · Potential for more than minimal harm
2024-08-15
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 2024-10-10
D · Potential for more than minimal harm
2024-08-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-10
C · Minimal harm
2024-08-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-05-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-22
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-22
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
E · Potential for more than minimal harm
2022-12-19
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 2023-02-27
E · Potential for more than minimal harm
2022-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-27
E · Potential for more than minimal harm
2022-12-19
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 2023-02-27
E · Potential for more than minimal harm
2022-12-19
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 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
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 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
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 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
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 2023-02-27
D · Potential for more than minimal harm
2022-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-19
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 2023-02-27
C · Minimal harm
2022-12-19
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2023-02-27
G · Actual harm
2020-03-12
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 2019-08-02
Penalties and ownership
What sits behind the stars
Ownership
Raleigh Court Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Charles 1994 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 LLC
5% Or Greater Indirect Ownership Interest · Organization
Flannagan, Korie
W-2 Managing Employee · Individual
Kss 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ml 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Rczbm West Manager LLC
Operational/Managerial Control · Organization
Redrock West LLC
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 LLC
5% Or Greater Indirect Ownership Interest · Organization
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
Brandon Oaks Nursing And Rehabilitation Center
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
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
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