Friendship Health And Rehab Center
327 Hershberger Rd NW, Roanoke, VA 24012 · Non profit - Corporation · 253 certified beds · (540) 265-2100 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.7% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 5.4% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.3% | 18.7% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.6% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.7% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.3% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 21.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.3% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.2% | 73.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.9% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.7% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.15 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.54 | 1.48 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 473 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 274 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.6%CMS range 56.6–66.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 8.0–12.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 93.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.0%CMS range 6.1–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 253 beds and averages 230.2 residents a day — about 91% occupied, or roughly 23 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 4.20 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.55 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · E2024-10-29 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and family interview the facility staff failed to provide an activities program designed to meet the needs of the residents for one of 5 units, memory care unit. The findings included: For the memory care unit, the facility staff failed to provide meaningful and engaging activities. Surveyor spoke with a family member on 10/23/24 at 1:20 pm. Resident's family member stated, They need more activities for these people, they just have them sitting in a room, waiting to die. They all just sit there and sleep. Surveyor made the following observations on the memory care unit: 10/23/24 at 2:05 pm-Residents seated in dining room, eating lunch. Staff stated lunch trays don't arrive on unit until around 1:00 pm. 10/23/24 at 4:10 pm-Residents sitting in dining room, music playing. No staff members observed in area. No activities observed. 10/24/24 at 9:50 am-Residents sitting in dining room, music playing. No activities observed and no staff members in area. 10/24/24 at 11:15 am-18 residents seated in dining room, around table or against the wall. Music…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and family interview the facility staff failed to maintain essential equipment for one of 35 residents, Resident #201. The findings included: For Resident #201 the facility staff failed to ensure the toilet was in proper working order. Resident #201's face sheet listed diagnoses which included but not limited to Alzheimer's disease and chronic kidney disease. Resident #201's most recent minimum data set with an assessment reference date of 08/14/24 coded the resident as having both and long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Surveyor spoke with Resident #201's family member on 10/23/24 at 1:20 pm. Resident's family member stated to surveyor, Have you looked in her bathroom, there is sh (word omitted) on the wall and everything. Surveyor observed Resident #201's bathroom on 10/23/24 at 4:10 pm. Surveyor observed a brownish substance on the toilet seat, front of toilet stool and wall in front of toilet. Surveyor pointed out brownish substance to unit manager, who stated they would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and clinical record review, the facility staff failed to follow medical provider orders for one (1) of 35 sampled residents (Resident #88). The findings include: The facility staff failed to administer Resident #88's Sevelamer as ordered by the medical provider. The medication had been scheduled to be administered during a time the resident was also scheduled to receive dialysis outside of the facility. (Sevelamer is medication given to individuals with chronic kidney disease. Sevelamer is used to manage an individual's phosphorus and/or calcium levels.) Resident #88's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/2/24, was signed as completed on 10/8/24. Resident #88 was assessed as usually being able to make self understood and as being able to understand others. Resident #88's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #88's medical record included a medical provider order for the resident to receive Sevelamer 800…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure complete and/or accurate clinical records for three (3) of 35 sampled residents (Resident #5, Resident #29, and Resident #88). The findings include: 1. The facility staff failed to document complete and/or accurate information related to Resident #88's wound care. Resident #88's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/2/24, was signed as completed on 10/8/24. Resident #88 was assessed as usually able to make self understood and as able to understand others. Resident #88's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. The following information was found in a facility policy titled Documentation Policy (with a date of March 2016): - Licensed Nurses and CNAs will document all pertinent nursing assessments, care interventions and follow up [sic] actions in the medical record. - Entries will be made as soon as possible after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-29 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review the facility staff failed to collaborate care with the contract Hospice company for 1 of 2 residents, Resident #331. The findings included: The facility staff failed to coordinate care with the contract Hospice company. The clinical record did not include Hospice visit notes. Resident #331's clinical record included the following diagnosis, malignant neoplasm of upper lobe, left bronchus or lung. There was no completed minimum data set (MDS) assessment for this resident. Resident #331's clinical record included provider orders to admit to Hospice 10/18/24. During the entrance conference the survey team requested information regarding the Hospice contracts. The facility staff provided the survey team with a copy of a Hospice contract that provided Resident 331's Hospice services. This document read in part, .Compliance of Records .Nursing facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving Nursing Facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to review and revise the residents CCP (comprehensive care plan) for 1 of 38 Residents, Resident #153. Resident #153's CCP was not revised when they were diagnosed with bilateral fractures and still included the intervention for TED hose. The findings included: Resident #153 clinical record included the diagnosis, periprosthetic fracture around internal prosthetic right and left knee joint, Alzheimer's disease, dementia, mixed receptive-expressive language disorder, muscle weakness, difficulty in walking, and cognitive communication deficit. Section C (cognitive patterns) of Resident #153's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/06/2022 was coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. Section G (functional status) was coded 3/3 to indicate the resident required extensive assistance of two persons for bed mobility and transfers. On 03/08/2022 a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure that residents who are unable to carry out ADLs (activities of daily living) receive the necessary care and services to maintain personal hygiene and grooming for 2 of 38 residents in the survey sample, Resident #32 and #74. For Resident #32, the facility staff failed to assist the resident with bathing. The facility staff failed to provide nail care for Resident #74. The findings included: 1. Resident #32's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 4, Type 2 Diabetes Mellitus with Proliferative Diabetic Retinopathy, Chronic Congestive Heart Failure, and Pulmonary Fibrosis. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 12/20/21 assigned the resident a BIMS (brief interview for mental status) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #32 was coded as requiring extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician's orders for 3 of 38 residents in the survey sample, Residents #16, #32, and #98. For Resident #16, the facility staff failed to apply an abdominal binder as ordered by the physician. For Resident #32, the facility staff failed to administered insulin as ordered by the physician. For Resident #98, the facility staff failed to administer insulin as ordered by the physician. The findings included: 1. Resident #16's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Bipolar Disorder, Hypertensive Heart Disease with Heart Failure, Dysphagia, Adult Failure to Thrive, and Cardiomegaly. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/13/21 assessed the resident as being severely cognitively impaired with short-term and long-term memory problems. The resident was coded for the presence of a feeding tube in which they received 51% or more of total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide urinary catheter care as ordered for 1 of 38 residents in the survey sample, Resident #165. The findings included: Resident #165's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease, Acute Kidney Failure with Tubular Necrosis, Retention of Urine, Dependence on Renal Dialysis, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Atrial Fibrillation, Osteoarthritis Right Knee, and Type 2 Diabetes Mellitus with Diabetic Neuropathic Arthropathy. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference rate) of 2/22/22 assigned the resident a BIMS (brief interview for mental status) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #165 was coded for the presence of an indwelling catheter. Resident #165's current comprehensive plan of care included focus areas stating in part, (Resident #165) requires extensive assistance with most of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure medications were secure and stored in locked compartments for 1 of 38 residents in the survey sample, Resident #189. For Resident #189, facility staff failed to ensure an AirDuo RespiClick inhaler (a medication used to treat asthma) was secure and stored in a locked compartment. The inhaler was stored in the resident's room on a bedside table. The findings included: Resident #189's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Pulmonary Fibrosis, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Chronic Combined Systolic and Diastolic Heart Failure, Venous Insufficiency, and Chronic Pain Syndrome. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/24/21 assigned the resident a BIMS (brief interview for mental status) summary score of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2021-06-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure accommodation of resident needs by failing to provide a method to call for staff assistance for 1 of 36 residents in the survey sample, Resident #79. The findings included: For Resident #79, the facility staff failed to provide a method to call for staff assistance. Resident #79's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease with Late Onset, Cognitive Communication Deficit, Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, Chronic Diastolic Congestive Heart Failure, and Type 1 Diabetes Mellitus with Hyperglycemia. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 4/23/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. In section G, Functional Status, Resident #79 was coded as requiring extensive assistance with bed mobility and personal hygiene and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-06-17 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement facility policy and procedures regarding reporting of all alleged violations involving abuse for 2 of 36 residents in the survey sample, Residents #173 and #131. The findings included: 1. For Resident #173, the facility staff failed to implement facility policy regarding reporting a resident to resident altercation occurring on 4/01/21. Resident #173's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease Unspecified, Unspecified Psychosis not due to Substance or Known Physiological Condition, Chronic Atrial Fibrillation Unspecified, Peripheral Vascular Disease Unspecified, and Major Depressive Disorder Recurrent Unspecified. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 5/29/21 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. A review of Resident #173's clinical record revealed the following documentation: A progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-06-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that all alleged violations involving abuse were reported for 2 of 36 residents in the survey sample, Residents # 173 and #131. The findings included: 1. For Resident #173, the facility staff failed to report a resident to resident altercation occurring on 4/01/21. Resident #173's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease Unspecified, Unspecified Psychosis not due to Substance or Known Physiological Condition, Chronic Atrial Fibrillation Unspecified, Peripheral Vascular Disease Unspecified, and Major Depressive Disorder Recurrent Unspecified. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 5/29/21 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. A review of Resident #173's clinical record revealed the following documentation: A progress note dated 4/01/21 19:55 (7:55 pm) states This writer assessed resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 1 of 36 residents in the survey sample, Resident #79. The findings included: For Resident #79, the facility staff failed to follow physician's orders for the administration of Hydralazine, a vasodilator used to treat high blood pressure. Resident #79's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease with Late Onset, Cognitive Communication Deficit, Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, Chronic Diastolic Congestive Heart Failure, Hypertensive Heart Disease with Heart Failure, and Type 1 Diabetes Mellitus with Hyperglycemia. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 4/23/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. Resident #79's physician's orders included an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-06-17 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 36 Residents was free of an unnecessary medication (Resident #77). The findings included: The facility nursing staff administered the hypertensive medication Metoprolol without adequate indications for use. Resident #77 clinical record included a physician order to hold this medication for a (BP) blood pressure less than 100 systolic (top number) or less than 60 diastolic (bottom number). The (EHR) electronic health record included the diagnosis, hypertensive chronic kidney disease, vascular dementia, and type 2 diabetes. Section C (cognitive patterns) of Resident #77's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 04/16/2021 included a (BIMS) brief interview for mental status summary score of 9 out of a possible 15 points. Resident #77's clinical record included a physicians order for Metoprolol 25 mg give 1 tablet by mouth every 12 hours for hypertension. Hold for systolic BP less than 100 or diastolic blood pressure less than 60. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility staff failed to dispose of stored expired laboratory tubes on 2 of 6 units, 2 South and 3 Main and failed to dispose of a stored expired medication on 1 of 6 units 2 North. The findings included: 1. The facility staff failed to dispose of stored expired laboratory tubes in the medication room on 2 South. 06/15/2021 at 12:10 p.m., the surveyor checked the medication room on 2 South with (LPN) licensed practical nurse #1. This medication room included 5 expired blue top laboratory tubes with an expiration date of 03/31/2021 and 1 expired purple top laboratory tube with an expiration date of 01/31/2021. LPN #1 stated she would dispose of the laboratory tubes. 06/16/21 at 3:41 p.m., the administrator and (DON) director of nursing were made aware of the expired laboratory tubes. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Unit 3 Main, the facility staff failed to discard stored expired lab specimen tubes. On 6/16/21 at 2:55 pm, in the presence of Unit Manager #1,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-06-17 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews the facility staff failed to maintain refrigerators in a safe and sanitary condition for 1 (one) of 6 (six) units (Unit 2 North). The findings: The facility staff failed to maintain the medication refrigerator and the pantry refrigerator on unit 2 North in a safe and sanitary condition. On 06/15/21 at 1:39 p.m., the medication refrigerator and the pantry refrigerator on unit 2 North was observed. One of the unit's licensed practical nurses (LPN#2) was present for the observations. The unit manager (LPN #1) was present for some of the refrigerator observations. The medication refrigerator had visible dust and debris throughout the inside. The shelves on the door as well as the bottom shelf and walls of the main refrigerated area had smears and spills of unknown substances. The unit manager (LPN#1) acknowledged the areas inside the refrigerator could be cleaned and reported the outside of the refrigerator was recently wiped down but the discolored areas on the outside could not be removed. The refrigerator in the pantry had numerous unknown…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BISHOP, NATHANIEL | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| COMBS, GLEN | Individual | CORPORATE DIRECTOR | since 03/01/2000 |
| FEINOUR, EDWIN | Individual | CORPORATE DIRECTOR | since 12/01/1990 |
| GROVE, LUCIAN | Individual | CORPORATE DIRECTOR | since 09/01/1999 |
| JOHNSON, CYNDA | Individual | CORPORATE DIRECTOR | since 07/01/2011 |
| LAWSON, ROBERT | Individual | CORPORATE DIRECTOR | since 03/07/2007 |
| OELSCHLAGER, KATHRYN | Individual | CORPORATE DIRECTOR | since 07/01/2011 |
| SANDEL, ROBERT | Individual | CORPORATE DIRECTOR | since 03/07/2007 |
| WILLIAMSON, JOHN | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| HOFF, JOSEPH | Individual | CORPORATE OFFICER | since 07/18/2017 |
| MITCHELL, CYNTHIA | Individual | CORPORATE OFFICER | since 04/06/2016 |
| SHANNON, CHARLES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2014 |
| FRIENDSHIP FOUNDATION INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 08/11/1987 |
CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495092. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.