01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-04-25 | 11 | 2024-04-25 | 2 |
| Cycle 2 | 2022-10-13 | 5 | 2022-10-13 | 10 |
| Cycle 3 | 2019-12-05 | 3 | 2019-12-05 | 5 |
CMS CCN 4954212026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Friendship Health And Rehab Center - South
5647 Starkey Road · Roanoke, VA 24018 · Roanoke County
Certified beds120CMS provider file
Recent citation rows36current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
36 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-18 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Past Non-Compliance · 2025-01-29 · complaint2025-06-18 · HEALTHF0761Severity J · isolated immediate jeopardy
Pharmacy Service Deficiencies
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.
Correction field: Past Non-Compliance · 2025-01-29 · complaint2024-04-25 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-06-20 · complaint2024-04-25 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-04-25 · FIREK0351Severity B · pattern; potential for minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-06-212024-04-25 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-06-212022-10-13 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2022-11-152022-10-13 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-11-152022-10-13 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2022-11-152022-10-13 · FIREK0293Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2022-12-052022-10-13 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Waiver has been granted · 2023-03-032022-10-13 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-03-032022-10-13 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Waiver has been granted · 2023-03-032022-10-13 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2022-12-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-06-18 | Fine | $8,281 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FRIENDSHIP FOUNDATION INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/15/2012
- EVANS, BRANDONIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 09/24/2018
- BISHOP, NATHANIELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2021
- COMBS, GLENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- FEINOUR, EDWINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- GROVE, LUCIANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- JOHNSON, CYNDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- LAWSON, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- OELSCHLAGER, KATHRYNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- SANDEL, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/15/2012
- WILLIAMSON, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2021
- HOFF, JOSEPHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/18/2017
- MITCHELL, CYNTHIAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/06/2016
- SHANNON, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/15/2012
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.24per resident day
RN hours0.57per resident day
Weekend nurse hours3.56per resident day
Staff turnover48.4%CMS reported field
06 / LOCAL RECORDS
Open the Roanoke ledger →Other published facilities nearby
Brandon Oaks Nursing And Rehabilitation Center62 beds · CMS overall 5/533 citation rowsDavis And Mcdaniel Veterans Care Center180 beds · CMS overall 5/520 citation rowsFriendship Health And Rehab Center253 beds · CMS overall 4/533 citation rowsOld Southwest Health And Rehabilitation130 beds · CMS overall 1/5156 citation rowsOur Lady Of The Valley70 beds · CMS overall 4/537 citation rowsPheasant Ridge Nursing And Rehabilitation101 beds · CMS overall 2/547 citation rowsRaleigh Court Health And Rehabilitation Center120 beds · CMS overall 4/548 citation rowsSouth Roanoke Nursing And Rehabilitation98 beds · CMS overall 3/559 citation rows