Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B
Grade
50
Score
CMS Ratings
6.6/22
Staffing Quality
7.7/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate58.8%
130
Total Beds
77
Occupied
53
Available

Basic Information

Address:

324 KING GEORGE AVE SW

ROANOKE, VA 24016

Number of Beds:

130

Estimated Occupancy:

59% (~54 available)

Chain:

EASTERN HEALTHCARE GROUP

Quality Ratings

Overall Rating:1/5 Stars
Health Inspection:1/5 Stars
Staffing Rating:2/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

495156

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Below Average

This Facility

0.42

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Below Average

This Facility

3.47

hours

National Avg

3.89

hours

Breakdown:

RN: 0.42hLPN: 1.31hAide: 1.73h

Staff Turnover Rate

Annual nursing staff turnover

Above Average

This Facility

69.5%

National Avg

46.6%

RN Turnover: 75.0%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

218

Inspections

6

High

6

Mar 29, 2024 - Health Survey

98 deficiencies cited

Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jul 16, 2024
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Jul 16, 2024
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Jul 16, 2024
Low - IsolatedTag F0575

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Corrected: Jul 16, 2024
Low - IsolatedTag F0577

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected: Jul 16, 2024
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Jul 16, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Aug 29, 2024
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jul 16, 2024
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Jul 16, 2024
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Aug 29, 2024
Medium - PatternTag F0625

Resident Rights Deficiencies

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: Aug 29, 2024
Medium - PatternTag F0636

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.

Corrected: Jul 16, 2024
Medium - PatternTag F0656

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.

Corrected: Jul 16, 2024
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Aug 29, 2024
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jul 16, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Aug 29, 2024
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Aug 29, 2024
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 29, 2024
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 16, 2024
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Jul 16, 2024
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Jul 16, 2024
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Aug 29, 2024
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Jul 16, 2024
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Aug 29, 2024
Medium - PatternTag F0756

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.

Corrected: Aug 29, 2024
Medium - PatternTag F0757

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected: Aug 29, 2024
High - Widespread PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Aug 29, 2024
Medium - PatternTag F0773

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected: Aug 29, 2024
Medium - PatternTag F0842

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.

Corrected: Aug 29, 2024
Medium - PatternTag F0865

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected: Aug 29, 2024
High - Widespread PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Jul 16, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Aug 29, 2024
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Aug 29, 2024
Medium - PatternTag F0887

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.

Corrected: Aug 29, 2024
Medium - PatternTag F0940

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected: Aug 29, 2024
Medium - PatternTag F0941

Administration Deficiencies

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected: Jul 16, 2024
Medium - PatternTag F0942

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected: Jul 16, 2024
Medium - PatternTag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected: Jul 16, 2024
Medium - PatternTag F0944

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected: Jul 16, 2024
Medium - PatternTag F0947

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected: Jul 16, 2024
Medium - PatternTag F0949

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected: Jul 16, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Jul 16, 2024From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0676

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected: Jul 16, 2024From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jul 16, 2024From Complaint
Medium - PatternTag F0578

Resident Rights Deficiencies

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: Aug 29, 2024From Complaint
Medium - PatternTag F0770

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0775

Administration Deficiencies

Keep complete, dated laboratory records in the resident's record.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Aug 29, 2024
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jul 16, 2024
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Jul 16, 2024
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Jul 16, 2024
Low - IsolatedTag F0575

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Corrected: Jul 16, 2024
Low - IsolatedTag F0577

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected: Jul 16, 2024
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Jul 16, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Aug 29, 2024
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jul 16, 2024
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Jul 16, 2024
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Aug 29, 2024
Medium - PatternTag F0625

Resident Rights Deficiencies

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: Aug 29, 2024
Medium - PatternTag F0636

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.

Corrected: Jul 16, 2024
Medium - PatternTag F0656

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.

Corrected: Jul 16, 2024
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Aug 29, 2024
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jul 16, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Aug 29, 2024
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Aug 29, 2024
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 29, 2024
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 16, 2024
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Jul 16, 2024
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Jul 16, 2024
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Aug 29, 2024
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Jul 16, 2024
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Aug 29, 2024
Medium - PatternTag F0756

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.

Corrected: Aug 29, 2024
Medium - PatternTag F0757

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected: Aug 29, 2024
High - Widespread PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Aug 29, 2024
Medium - PatternTag F0773

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected: Aug 29, 2024
Medium - PatternTag F0842

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.

Corrected: Aug 29, 2024
Medium - PatternTag F0865

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected: Aug 29, 2024
High - Widespread PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Jul 16, 2024
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Aug 29, 2024
Medium - PatternTag F0887

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.

Corrected: Aug 29, 2024
Medium - PatternTag F0940

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected: Aug 29, 2024
Medium - PatternTag F0941

Administration Deficiencies

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected: Jul 16, 2024
Medium - PatternTag F0942

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected: Jul 16, 2024
Medium - PatternTag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected: Jul 16, 2024
Medium - PatternTag F0944

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected: Jul 16, 2024
Medium - PatternTag F0947

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected: Jul 16, 2024
Medium - PatternTag F0949

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected: Jul 16, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Jul 16, 2024From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0676

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected: Jul 16, 2024From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jul 16, 2024From Complaint
Medium - PatternTag F0578

Resident Rights Deficiencies

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: Aug 29, 2024From Complaint
Medium - PatternTag F0770

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected: Aug 29, 2024From Complaint
Medium - PatternTag F0775

Administration Deficiencies

Keep complete, dated laboratory records in the resident's record.

Corrected: Aug 29, 2024From Complaint

Nov 1, 2023 - Health Survey

30 deficiencies cited

Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0656

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.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Jan 18, 2024From Complaint
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0687

Quality of Life and Care Deficiencies

Provide appropriate foot care.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0656

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.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Jan 18, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0842

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.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0761

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.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0761

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.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0842

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.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0687

Quality of Life and Care Deficiencies

Provide appropriate foot care.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Jan 18, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Jan 18, 2024From Complaint

Feb 23, 2023 - Health Survey

4 deficiencies cited

Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Mar 21, 2023From Complaint
Medium - PatternTag F0567

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Corrected: Mar 21, 2023From Complaint
Medium - PatternTag F0567

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Corrected: Mar 21, 2023From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Mar 21, 2023From Complaint

Nov 7, 2022 - Health Survey

10 deficiencies cited

Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Jan 10, 2023
Medium - PatternTag F0842

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.

Corrected: Jan 10, 2023From Complaint
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Jan 10, 2023
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Jan 10, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jan 10, 2023From Complaint
Medium - PatternTag F0842

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.

Corrected: Jan 10, 2023From Complaint
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Jan 10, 2023From Complaint
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Jan 10, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jan 10, 2023From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Jan 10, 2023From Complaint

Jul 19, 2022 - Health Survey

28 deficiencies cited

Medium - PatternTag F0625

Resident Rights Deficiencies

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: Aug 22, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

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: Aug 22, 2022
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Aug 22, 2022
Medium - PatternTag F0625

Resident Rights Deficiencies

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: Aug 22, 2022
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Aug 22, 2022
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Aug 22, 2022
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Aug 22, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Aug 22, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 22, 2022
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Aug 22, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Aug 22, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Aug 22, 2022
Medium - PatternTag F0756

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.

Corrected: Aug 22, 2022
Medium - PatternTag F0761

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.

Corrected: Aug 22, 2022
Medium - PatternTag F0842

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.

Corrected: Aug 22, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

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: Aug 22, 2022
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Aug 22, 2022
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Aug 22, 2022
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Aug 22, 2022
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Aug 22, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Aug 22, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 22, 2022
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Aug 22, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Aug 22, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Aug 22, 2022
Medium - PatternTag F0756

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.

Corrected: Aug 22, 2022
Medium - PatternTag F0761

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.

Corrected: Aug 22, 2022
Medium - PatternTag F0842

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.

Corrected: Aug 22, 2022

Aug 5, 2021 - Health Survey

48 deficiencies cited

High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Sep 23, 2021
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Sep 23, 2021
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Oct 15, 2021
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Oct 15, 2021
Medium - PatternTag F0656

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.

Corrected: Oct 15, 2021
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Sep 23, 2021
Medium - PatternTag F0622

Resident Rights Deficiencies

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: Sep 23, 2021
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Sep 23, 2021
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Sep 23, 2021
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Sep 23, 2021
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Sep 23, 2021
Medium - PatternTag F0919

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected: Oct 15, 2021
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Sep 23, 2021
Medium - PatternTag F0842

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.

Corrected: Sep 23, 2021
Medium - PatternTag F0772

Administration Deficiencies

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

Corrected: Sep 23, 2021
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Sep 23, 2021
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Sep 23, 2021
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Sep 23, 2021
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Sep 23, 2021
Medium - PatternTag F0622

Resident Rights Deficiencies

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: Sep 23, 2021
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Sep 23, 2021
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Sep 23, 2021
Medium - PatternTag F0656

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.

Corrected: Oct 15, 2021
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Oct 15, 2021
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Oct 15, 2021
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Sep 23, 2021
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Sep 23, 2021
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Sep 23, 2021
Medium - PatternTag F0691

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected: Sep 23, 2021
Medium - PatternTag F0761

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.

Corrected: Sep 23, 2021
Medium - PatternTag F0756

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.

Corrected: Sep 23, 2021
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Sep 23, 2021
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Sep 23, 2021
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Oct 15, 2021
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Sep 23, 2021
Medium - PatternTag F0919

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected: Oct 15, 2021
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Sep 23, 2021
Medium - PatternTag F0842

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.

Corrected: Sep 23, 2021
Medium - PatternTag F0772

Administration Deficiencies

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

Corrected: Sep 23, 2021
Medium - PatternTag F0761

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.

Corrected: Sep 23, 2021
Medium - PatternTag F0756

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.

Corrected: Sep 23, 2021
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Sep 23, 2021
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Sep 23, 2021
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Oct 15, 2021
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Sep 23, 2021
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Sep 23, 2021
Medium - PatternTag F0691

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected: Sep 23, 2021
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Sep 23, 2021

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

2 penalties in the past 3 years

Total fines: $135,633

FineMarch 29, 2024

$135,633

Data processed: August 1, 2026

Payment DenialMarch 29, 2024

Payment Denial: Started June 29, 2024

Duration: 61 days

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

🛏
Beds Available
Approximately 54 beds potentially available
🏢
Part of Healthcare Chain
EASTERN HEALTHCARE GROUP

Frequently Asked Questions

What is the quality rating for OLD SOUTHWEST HEALTH AND REHABILITATION?

OLD SOUTHWEST HEALTH AND REHABILITATION has an overall CMS rating of 1 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

OLD SOUTHWEST HEALTH AND REHABILITATION has 130 certified beds. The facility averages 77 residents per day, with an occupancy rate of approximately 59%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the EASTERN HEALTHCARE GROUP network.

How can I contact OLD SOUTHWEST HEALTH AND REHABILITATION?

You can call OLD SOUTHWEST HEALTH AND REHABILITATION at (540)345-8139. The facility is located at 324 KING GEORGE AVE SW, ROANOKE, VA 24016.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: