11 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Roanoke, VA
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
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
Chain footprint
16 facilities
Chain averages 4 overall / 4 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
RN hours / resident day
0.51
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
5,988
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.67
Baseline 19.88% · Performance 20.20% · Measure score 2.67 · Achievement 2.67 · Improvement 0
Healthcare-associated infections
2.10
Baseline 9.13% · Performance 8.05% · Measure score 2.10 · Achievement 0 · Improvement 2.10
Total nurse turnover
7.66
Baseline 47.83% · Performance 32.35% · Measure score 7.66 · Achievement 7.66 · Improvement 6.23
Adjusted total nurse staffing
1.31
Baseline 3.15 hours · Performance 3.45 hours · Measure score 1.31 · Achievement 1.31 · Improvement 0.65
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 2.22% · Lower 95% interval 6.22% |
| Discharge to community | 44.01% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 36.11% · Lower 95% interval 30.89% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 90% |
95.27%
5.3 pts worse
|
Numerator 27 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 73.08% |
53.69%
19.4 pts better
|
Numerator 19 · Denominator 26 |
| Discharge mobility score | 73.08% |
50.94%
22.1 pts better
|
Numerator 19 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.05% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 12.12% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 10.75% |
8.2%
2.6 pts better
|
Numerator 10 · Denominator 93 |
| Staff flu vaccination coverage | 20% |
42%
22 pts worse
|
Numerator 21 · Denominator 105 |
| Discharge function score | 76.92% |
56.45%
20.5 pts better
|
Numerator 20 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 7 · Denominator 21 |
Quality measures
| 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 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 97.4% · Q2 96.2% · Q3 96.1% · Q4 98.7% · 4Q avg 97.1% |
| 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 · 4Q avg 96.6% |
| 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 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 2.7% · Q2 5.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% |
| 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 · Q1 2.3% · Q2 5.2% · Q3 5.5% · Q4 5.2% · 4Q avg 4.7% |
| 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 · Q1 13.9% · Q2 16.4% · Q3 17.1% · Q4 16.9% · 4Q avg 16.1% |
| 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 · Q1 4.7% · Q2 6.7% · Q3 4.5% · Q4 1.5% · 4Q avg 4.3% · 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 | 16.4% |
17.5%
1.1 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 37.4% · Q3 7.3% · Q4 11.0% · 4Q avg 16.4% · Used in QM five-star |
| 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 · Q1 20.3% · Q2 26.5% · Q3 2.9% · Q4 11.8% · 4Q avg 15.4% · 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 | 0.3% |
1.6%
1.3 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| 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 · Q1 22.5% · Q2 25.0% · Q3 14.8% · Q4 15.3% · 4Q avg 19.4% |
| 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 · Q1 2.7% · Q2 2.3% · Q3 1.7% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| 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 · Q1 60.8% · Q2 83.6% · Q3 92.9% · Q4 78.2% · 4Q avg 79.4% |
| 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 · Adjusted 2.6% · Observed 2.4% · Expected 10.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 31.1% |
| 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 · Adjusted 18.3% · Observed 19.5% · Expected 25.4% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Infection Control (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (5 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-03
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-06-03
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-03
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-03
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-03
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-31
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-31
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
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-07
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2019-08-23
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-23
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-08-23
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-08-23
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-08-23
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-08-23
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-08-23
Fire Safety
Establish methods for sharing information.
Corrected 2019-08-23
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-08-23
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-08-23
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-08-23
Inspection history
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
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2025-06-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-03
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
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
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
Health
Assess the resident when there is a significant change in condition
Corrected 2025-06-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-03
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
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-05-08
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-05-08
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-05-08
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
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-05-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-08
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
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-08
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-05-08
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-05-08
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
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-08
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
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-23
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
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
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
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
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-08-23
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
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
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
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
Health
Have policies on smoking.
Corrected 2019-08-23
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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