Cycle 1
Health 2025-04-24 · Fire 2025-04-24
11 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Roanoke, VA
South Roanoke Nursing And Rehabilitation
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3823 Franklin Rd, Sw, Roanoke, VA
(540) 344-4325
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
98
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Heritage Hall
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
1.92
Nurse aide staffing
Weekend hours
2.80
Weekend nurse staffing
RN turnover
31%
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 | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.2%
5.9 pts better
|
93.4%
3.7 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 | 1.3% |
3.6%
2.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
15.7%
13.6 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.7%
1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
20.2%
4.1 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
15.0%
10.7 pts better
|
16.7%
12.4 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 | 16.4% |
17.5%
1.1 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
15.7%
0.3 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.6%
1.3 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
22.2%
2.8 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.2%
3.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.4% |
74.6%
4.8 pts better
|
81.7%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.6% |
11.7%
9.1 pts better
|
12.0%
9.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.1% |
73.6%
42.5 pts worse
|
79.7%
48.6 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
22.0%
3.7 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-24 · Fire 2022-03-24
14 health deficiencies
Top issue: Infection Control (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-07-09 · Fire 2019-07-09
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-24
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-24
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-24
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-03
E · Potential for more than minimal harm
2022-03-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-03-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-31
F · Potential for more than minimal harm
2019-07-09
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 2019-08-07
F · Potential for more than minimal harm
2019-07-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-07-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-08-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-24
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 2025-06-03
F · Potential for more than minimal harm
2025-04-24
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-24
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 2025-06-03
E · Potential for more than minimal harm
2025-04-24
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 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
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 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-03
F · Potential for more than minimal harm
2022-03-24
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 2022-05-08
F · Potential for more than minimal harm
2022-03-24
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-05-08
F · Potential for more than minimal harm
2022-03-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-05-08
F · Potential for more than minimal harm
2022-03-24
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-03-24
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 2022-05-08
D · Potential for more than minimal harm
2022-03-24
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 2022-05-08
D · Potential for more than minimal harm
2022-03-24
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 2022-05-08
D · Potential for more than minimal harm
2022-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-03-24
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 2022-05-08
D · Potential for more than minimal harm
2022-03-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-03-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-03-24
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-03-24
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 2022-05-08
D · Potential for more than minimal harm
2022-03-24
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-08
F · Potential for more than minimal harm
2019-07-09
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 2019-08-23
F · Potential for more than minimal harm
2019-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-23
E · Potential for more than minimal harm
2019-07-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
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 2019-08-23
D · Potential for more than minimal harm
2019-07-09
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-09
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 2019-08-23
D · Potential for more than minimal harm
2019-07-09
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 2019-08-23
D · Potential for more than minimal harm
2019-07-09
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 2019-08-23
D · Potential for more than minimal harm
2019-07-09
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 2019-08-23
D · Potential for more than minimal harm
2019-07-09
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2019-08-23
Penalties and ownership
What sits behind the stars
Ownership
American Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare LLC
Operational/Managerial Control · Organization
Champney, Christian
Operational/Managerial Control · Individual
Dalton, Brad
Operational/Managerial Control · Individual
Dalton, Brad
Corporate Officer · Individual
Dalton, Robert
Operational/Managerial Control · Individual
Dalton, Robert
Corporate Officer · Individual
East, Thomas
Corporate Officer · Individual
Gallant, Cassandra
Operational/Managerial Control · Individual
Hopkins, William
Corporate Director · Individual
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3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
Friendship Health And Rehab Center - South
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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
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