Cycle 1
Health 2024-02-14 · Fire 2024-02-14
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Roanoke, VA
Star City Rehabilitation And Nursing
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1047 Mecca Street Ne, Roanoke, VA
(540) 924-0100
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eastern Healthcare Group
Operator or chain grouping
Approved since
2021-09-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 1 overall / 2 health / 1 staffing / 3 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
0.22
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
2.88
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,199
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.53
Baseline 16.57% · Performance 21.19% · Measure score 0.53 · Achievement 0.53 · Improvement 0
Healthcare-associated infections
8.87
Baseline 5.27% · Performance 5.18% · Measure score 8.87 · Achievement 8.87 · Improvement 2.71
Total nurse turnover
1.20
Performance 58.76% · Measure score 1.20 · Achievement 1.20 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.58
Baseline 4.42 hours · Performance 3.53 hours · Measure score 1.58 · Achievement 1.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 303 · Observed rate 10.23% · Lower 95% interval 7.85% |
| Discharge to community | 56.97% |
50.57%
6.4 pts better
|
Better than the National Rate · Eligible stays 317 · Observed rate 51.42% · Lower 95% interval 52.07% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.53% |
95.27%
2.3 pts better
|
Numerator 158 · Denominator 162 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 162 |
| Discharge self-care score | 75.23% |
53.69%
21.5 pts better
|
Numerator 82 · Denominator 109 |
| Discharge mobility score | 67.89% |
50.94%
17 pts better
|
Numerator 74 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 162 · Adjusted rate 2% |
| Healthcare-associated infections requiring hospitalization | 5.18% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 2.91% · Lower 95% interval 3.16% |
| Staff COVID-19 vaccination coverage | 7.31% |
8.2%
0.9 pts worse
|
Numerator 16 · Denominator 219 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 330 |
| Discharge function score | 74.31% |
56.45%
17.9 pts better
|
Numerator 81 · Denominator 109 |
| Transfer of health information to provider | 96.05% |
95.95%
0.1 pts better
|
Numerator 73 · Denominator 76 |
| Transfer of health information to patient | 98.15% |
96.28%
1.9 pts better
|
Numerator 53 · Denominator 54 |
| Resident COVID-19 vaccinations up to date | 8.05% |
25.2%
17.1 pts worse
|
Numerator 7 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.4
0.4 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.3% |
91.2%
8.9 pts worse
|
93.4%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 67.4% · Q3 80.9% · Q4 92.8% · 4Q avg 82.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 54.2% |
94.0%
39.8 pts worse
|
95.5%
41.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 54.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.3% · Q3 3.4% · Q4 6.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
15.7%
11.2 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 7.6% · Q3 0.0% · Q4 1.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 9.4% |
5.7%
3.7 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 9.1% · Q3 10.1% · Q4 10.3% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
20.2%
0.8 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 18.8% · Q3 17.7% · Q4 23.0% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
15.0%
0.5 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 21.3% · Q3 14.1% · Q4 16.9% · 4Q avg 15.5% · 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 | 19.1% |
17.5%
1.6 pts worse
|
16.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 13.5% · Q3 8.7% · Q4 19.9% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
15.7%
5.5 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 17.1% · Q3 25.0% · Q4 12.1% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.6%
0.7 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
22.2%
0.4 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 23.8% · Q3 23.2% · Q4 24.5% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.2%
1.1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.1% · Q3 6.4% · Q4 7.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.9% |
74.6%
30.7 pts worse
|
81.7%
37.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 21.9% · Q3 46.7% · Q4 64.7% · 4Q avg 43.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.7%
0.1 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.1% |
73.6%
41.5 pts worse
|
79.7%
47.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
22.0%
3.6 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 26.1% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-08 · Fire 2021-09-08
22 health deficiencies
Top issue: Nutrition and Dietary (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-14
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-18
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-18
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-18
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-18
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-18
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 2025-03-25
E · Potential for more than minimal harm
2025-02-18
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 2025-03-25
E · Potential for more than minimal harm
2025-02-18
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-18
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 2025-03-25
D · Potential for more than minimal harm
2025-02-18
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 2025-03-25
D · Potential for more than minimal harm
2025-02-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-18
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 2025-03-25
D · Potential for more than minimal harm
2025-02-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-18
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 2025-03-25
D · Potential for more than minimal harm
2025-02-18
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-25
E · Potential for more than minimal harm
2024-11-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-08
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 2024-12-12
E · Potential for more than minimal harm
2024-11-08
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-08
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-08
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-02-14
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 2024-04-18
E · Potential for more than minimal harm
2024-02-14
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 2024-04-18
D · Potential for more than minimal harm
2024-02-14
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
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 2024-04-18
D · Potential for more than minimal harm
2024-02-14
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 2024-04-18
D · Potential for more than minimal harm
2024-02-14
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 2024-04-18
D · Potential for more than minimal harm
2024-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-18
Penalties and ownership
What sits behind the stars
Ownership
Va SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Lyam Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ydi Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Shapiro, Akiva
Corporate Officer · Individual
Vanhousen, Susan
W-2 Managing Employee · Individual
Nearby options
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3-star overall rating with 3-star inspections with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Berkshire Health & Rehabilitation Center
Vinton, VA
4-star overall rating with 4-star inspections with 8 recent health deficiencies
#3
Our Lady Of The Valley
Roanoke, VA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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