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Friendship Health And Rehab Center - South

5647 Starkey Road, Roanoke, VA 24018 · Non profit - Corporation · 120 certified beds · (540) 777-8300 Medicare & Medicaid certified

Call the home — (540) 777-8300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,281 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,281 in federal fines (most recent 2025-06-18)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4035 Electric Rd Ste A · (540) 772-8670 · Call to confirm hours
Pharmacy
3534 Electric Rd · (540) 339-9446 · Call to confirm hours
Grocery
4710 Starkey Rd · (540) 566-3933 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 5 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 fell from 4 to 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.3%14.9%15.4%typical
Long-stay residents who lose too much weight2.2%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%1.6%2.0%better
Long-stay residents with depressive symptoms12.0%18.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%3.6%3.3%better
Long-stay residents whose ability to walk worsened10.7%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.2%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%94.0%95.3%typical
Long-stay residents with pressure ulcers6.9%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control14.2%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.1%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine95.4%73.6%79.4%better
Short-stay residents rehospitalized after admission25.0%22.3%22.6%worse
Short-stay residents with an outpatient ER visit12.6%11.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.251.521.67better
Long-stay outpatient ER visits per 1,000 resident days1.151.481.80better

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.

66.9% 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 579 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.9%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
54.0%U.S. median 56.6%
Met the expected recovery
0.75U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.33hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 54.0% 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 263 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 0.75 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.9%CMS range 63.5–70.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 8.1–12.710.7%Oct 2022–Sep 2024no 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 discharge54.0%56.6%Oct 2024–Sep 2025CMS 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 discharge61.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge62.0%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting86.2%100.0%Oct 2024–Sep 2025CMS 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 discharge97.5%98.7%Oct 2024–Sep 2025CMS 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 stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.5–9.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 2022–Sep 2024CMS 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

0.57
RN hours/ resident / day
1.37
LPN hours/ resident / day
2.31
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.38
RN hoursweekends
48.4%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 112.4 residents a day — about 94% occupied, or roughly 8 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 3.56 hrs/resident/day on weekends vs 4.52 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.38 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

11
deficiencies at the latest standard inspection (2024-04-25)
3
at the previous standard inspection (2022-10-13)

Deficiencies are more than at the previous inspection — worsening. 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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.

19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-06-18 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    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 accurately label medications for 1 of 2 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to ensure the medication Morphine Sulfate was labeled with the correct dosage, resulting in the resident receiving multiple incorrect doses. Resident #1's face sheet listed diagnoses which included but not limited to multiple sclerosis, epilepsy, long term use of opiate analgesic, and personal history of traumatic brain injury. Resident #1's most recent minimum data set with an assessment reference date of 11/18/24 assigned the resident a brief interview for mental status score of 3 out of 15. This indicates that the resident is severely cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a plan for . has dx (diagnosis) of MS (multiple sclerosis) with chronic pain . Interventions for this care plan included Administer medications as per orders. See MAR (medication administration record) for details. Resident #1's…

    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.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-06-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility policy review the facility staff failed to follow professional standards of practice for the administration of medications for 1 of 2 residents, Resident #1. The finding included: For Resident #1 the facility staff failed compare the medication label to the physician's order, resulting in the resident receiving multiple incorrect doses of the medication morphine sulfate. Resident #1's face sheet listed diagnoses which included but not limited to multiple sclerosis, epilepsy, long term use of opiate analgesic, and personal history of traumatic brain injury. Resident #1's most recent minimum data set with an assessment reference date of 11/18/24 assigned the resident a brief interview for mental status score of 3 out of 15. This indicates that the resident is severely cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a plan for . has dx (diagnosis) of MS (multiple sclerosis) with chronic pain . Interventions for this care plan included Administer medications as per orders. See MAR…

    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.

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · E2024-04-25 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 4 of 26 residents, #57, #76, #18, and #44. The findings included: 1. For Resident #57 the facility staff failed to ensure the medication Tylenol 500 mg was available for administration. Resident #57's face sheet listed diagnoses which included but not limited to rheumatoid arthritis, anxiety disorder, osteoarthritis, and scoliosis. Resident #57's most recent minimum data set with an assessment reference date of 02/19/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #57's comprehensive care plan was reviewed and contained a care plan for . reports frequent pain that she attributes to RA (rheumatoid arthritis) to hands that does not interfere with sleep and occasionally limits day-to-day activities . Interventions for this care plan include…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 ensure 1 of 26 residents was clinically appropriate for self-administration of medications. The findings included: For Resident #56 the facility staff failed to complete a self-administration of medications assessment. Resident #56's face sheet listed diagnoses which included but not limited to traumatic subdural hematoma without loss of consciousness, quadriplegia, moderate persistent asthma, and personal history of other diseases of the respiratory system. Resident #56's most recent minimum data set with an assessment reference date of 01/21/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #56's comprehensive care plan was reviewed, and surveyor could not locate a care plan for self-administration of medications. Resident #56's physician's order summary was reviewed and contained orders which read in part, Advair HFA…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 26 residents, Resident #50. The findings included: For Resident #50 the facility staff failed to code the MDS assessment for use of a CPAP (continuous positive airway pressure) machine. Resident #50's face sheet listed diagnoses which included but not limited to encephalopathy, Parkinson's disease, and obstructive sleep apnea. Resident #50's most recent MDS with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section O, Special Treatments, Procedures and Programs, subsection G3, CPAP, was not coded at being used. Resident #50's comprehensive care plan was reviewed, and surveyor could not locate a care plan for use of CPAP. Resident #50's clinical record was reviewed and contained a physician's order summary for the month of April.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, resident interview, clinical record review, and facility document review the facility staff failed to develop a comprehensive care plan for 2 of 26. residents, #50 and #56. The findings included: 1. For Resident #50 the facility staff failed to develop a care plan for use of a CPAP (continuous positive airway pressure) machine. Resident #50's face sheet listed diagnoses which included but not limited to encephalopathy, Parkinson's disease, and obstructive sleep apnea. Resident #50's most recent MDS with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section O, Special Treatments, Procedures and Programs, subsection G3, CPAP was not coded at being used. Resident #50's comprehensive care plan was reviewed, and surveyor could not locate a care plan for use of CPAP. Resident #50's clinical record was reviewed and contained a physician's order summary for the month of April.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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, clinical record review, and facility document review the facility staff failed to ensure 1 of 26 residents was free from unnecessary medications, Resident #44. The findings included: For Resident #44 the facility staff administered the blood pressure medication, Metoprolol outside of the physician ordered parameters. Resident #44's face sheet listed diagnoses which included but not limited to diastolic (congestive) heart failure, and hypertensive heart disease. Resident #44's most recent minimum data set with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 7 out of 15 is section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #44's comprehensive care plan was reviewed and contained a care plan for .has a health history of Alzheimer's Dementia with anxiety, AFIB (atrial fibrillation), HTN (hypertension [high blood pressure]), age related debility among other co-morbidities. Interventions for this care plan include provide medications/treatments as…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 provide adequate monitoring for residents receiving psychotropic medications for one of 26 residents in the survey sample, resident # 65. This findings included: For resident # 65 the facility staff failed to implement behavior monitoring or nonpharmacologic interventions for several psychotropic medications prescribed. Resident # 65's diagnoses included but were not limited to, anxiety, depression, history of stroke, diabetes and obstructive sleep apnea. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/6/24 assigned the resident a brief interview for mental status (BIMS) score of 15 indicating intact cognition . Resident # 65 was coded as feeling down or depressed 2-6 days in the lookback period. No behaviors were noted in the lookback period according to the MDS. Review of the clinical record revealed that resident # 65 was prescribed Abilify 2 mg everyday by mouth for a diagnosis of depression(Abilify is classified as an antipsychotic…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 1 of 26 residents was free of significant medication errors, Resident #6. The findings included: For Resident #6 the facility staff failed to administer the medication Levothyroxine per the physcian's order. Resident #6's face sheet listed diagnoses which included but not limited to post procedural hypothyroidism. Resident #6's most recent minimum data set with an assessment reference date of 02/04/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #6's comprehensive care plan was reviewed and contained a care plan for .has a health history of type II diabetes mellitus with neuropathic/ophthalmic complication, anemia, . and other co-morbidities. Interventions for this care plan include Provide medications/treatments as ordered. Resident #6's clinical record was reviewed and contained a physician's order summary which read in part,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. For Resident #60, the facility staff failed to document in the clinical record the responsible party's decision to decline the influenza, pneumococcal, and updated 2023-2024 formula COVID-19 vaccines. Resident #60's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Panic Disorder, and Psychotic Disorder with Delusions. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/17/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. According to Resident #60's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 1/25/21, 2/15/21, 6/14/22, 10/20/22 and the most recent influenza vaccine was received on 10/12/22. The resident's immunization documentation did not include a history of any previous pneumococcal vaccines. Surveyor reviewed Resident #60's clinical record and was unable to locate evidence…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility document review, the facility staff failed to ensure individuals providing resident care correctly performed hand hygiene. The findings include: A contract staff member (SM #20) failed to perform hand hygiene between facility residents when providing toenail care. The following information was found in a facility policy and procedure titled Handwashing (with a revised date of 3/18/23): - It is the policy of this facility that hand washing be regarded as the single most important means of preventing the spread of infections. - The use of gloves does not replace the need for hand hygiene by either alcohol based waterless hand rubs or hand washing with soap and water. - Handwashing to be performed for at least twenty (20) seconds under the following conditions: . Before and after having contact with a resident (i.e., bed bath, changing linen, etc.) . After contact with inanimate objects to include medical equipment in the vicinity of the patient . On 4/25/24 at 1:10 p.m., a contract staff member (SM #20) was observed to finish…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2024-04-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine to 2 of 5 sampled residents (Resident #24 and #76) in accordance with nationally recognized standards. 1. For Resident #24, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, and Thoracic Aortic Aneurysm. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/08/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #24's immunization history documented in the clinical record,…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0887 — isolated
    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.
    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 offer an updated 2023-2024 formula COVID-19 vaccine for 3 of 5 sampled residents, Resident #3, #24, and #75. The findings included: 1. For Resident #3, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Hypertensive Chronic Kidney Disease, Chronic Embolism and Thrombosis of Left Femoral Vein, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/12/24 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. According to Resident #3's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 1/30/21, 2/20/21, and 12/15/21. Surveyor reviewed Resident #3's clinical record and was unable to locate evidence of the resident being offered an updated 2023-2024 formula…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 interviews and clinical record review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming, personal and oral care for one (1) of 26 sampled residents, Resident #62. The findings were: The facility staff failed to provide appropriate activities of daily living (ADLs), specifically combing hair, washing hands, washing face, shaving, and brushing teeth, for Resident #62. Resident #62's admission record listed diagnoses which included but were not limited to hemiplegia (total or partial paralysis of one side) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, aphasia (language disorder), dysphagia (difficulty swallowing), and apraxia (speech disorder) following cerebral infarction, lack of coordination, and repeated falls. The minimum data set assessment with an assessment reference date of 09/12/22 indicated Resident #62 should not have a brief interview for mental status conducted due to the resident being rarely/never understood. In Section C…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-13 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications/supplements were stored in a locked compartment in a resident room for 1 of 24 (Resident #27), failed to label and store medication appropriately on 1 of 4 wings (wing 1), failed to keep medications in direct line of sight until administered for 1 of 4 Residents during a medication pass (Resident #10), and failed to lock an unattended medication cart on 1 of 4 wings (wing 3). The findings include: 1. For Resident #27, the facility staff failed to store supplements in a locked compartment. Resident #27 had been approved to self-administer their supplements these were observed to be kept in an unlocked drawer in the residents room. Resident #27's diagnosis included, but were not limited to, quadriplegia and polyneuropathy. Section C (cognitive patterns) of Resident #27's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 07/22/22 included 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-13 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 drug regimen reviews were acted upon for 2 of 5 residents in the survey sample reviewed for unnecessary medications, Resident #75 and #37. The findings included: 1. For Resident #75, the facility staff failed to address drug regimen reviews completed by the pharmacist for the months of April 2022, June 2022, July 2022, and August 2022 each requesting a gradual dose reduction (GDR) review for the antidepressant medications Sertaline and Trazodone. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Paroxysmal Atrial Fibrillation, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 9/02/22 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Upon 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility document review, and during a medication pass and pour observation, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary, environment and help prevent the development and transmission of communicable disease and infections on 1 of 4 facility wings, Wing #3. The findings included: During a medication pass and pour observation, the facility staff failed to perform hand hygiene and failed to sanitize vital sign equipment between resident uses. On 10/12/22 at 8:55 am, during a medication pass and pour observation, surveyor observed licensed practical nurse (LPN) #4 obtain Resident #44's blood pressure and oxygen saturation utilizing a Dinamap vital sign machine. LPN #4 placed the blood pressure cuff on the resident's arm and the oxygen sensor on the resident's finger. LPN #4 failed to sanitize the blood pressure cuff or the oxygen finger sensor following use and immediately returned the Dinamap vital sign machine to the hall storage area. The vital sign machine included an attached compartment…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, staff interview and clinical record review the facility staff failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for one of 28 residents, Resident #41. The findings included: For Resident #41 the facility staff failed to ensure personal hygiene was maintained. Resident #41's face sheet included diagnoses not limited to dysphagia, aphasia, cognitive communication deficit, anxiety, and dementia without behavioral disturbance. Resident #41's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/22/19 assigned the resident a BIMS (brief interview for mental status) score of 7 out of 15 in section C, cognitive patterns. Section E, behaviors, indicated the resident has no behaviors of rejecting care. Section G, functional status, coded the resident as needing extensive physical assistance of one person in the areas of personal hygiene and bathing. Resident #41's comprehensive care plan was reviewed and contained a care plan for .has 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-05 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to store expired biological's in 2 of 4 medication rooms (unit 1 and unit 2) and failed to properly store an unused IV antibiotic for 1 of 28 Residents, Resident #94. The findings included: 1. The medication storage rooms on unit 1 and unit 2 included 3 bottles of expired chemstrips (urine test strips). These bottles had expired on [DATE]. On [DATE] at approximately 3:28 p.m., the surveyor checked the medication storage room on unit 1 with RN (registered nurse) #1. This medication room included 1 bottle of expired chemstrips. RN #1 reviewed the label with the surveyor, verbalized the strips were out of date, and stated they would toss the expired bottle. On [DATE] at 3:41 p.m., the surveyor and RN #1 checked the medication storage room on unit 2. This medication storage room included 2 bottles of expired chemstrips. RN #1 reviewed the chemstrip labels with the surveyor, verbalized both bottles were out of date, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,281 in federal fines across 1 penalty.

  • $8,281 — penalty dated 2025-06-18

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
FRIENDSHIP FOUNDATION INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/15/2012
EVANS, BRANDONIndividualW-2 MANAGING EMPLOYEEsince 09/24/2018
BISHOP, NATHANIELIndividualCORPORATE DIRECTORsince 07/01/2021
COMBS, GLENIndividualCORPORATE DIRECTORsince 03/15/2012
FEINOUR, EDWINIndividualCORPORATE DIRECTORsince 03/15/2012
GROVE, LUCIANIndividualCORPORATE DIRECTORsince 03/15/2012
JOHNSON, CYNDAIndividualCORPORATE DIRECTORsince 03/15/2012
LAWSON, ROBERTIndividualCORPORATE DIRECTORsince 03/15/2012
OELSCHLAGER, KATHRYNIndividualCORPORATE DIRECTORsince 03/15/2012
SANDEL, ROBERTIndividualCORPORATE DIRECTORsince 03/15/2012
WILLIAMSON, JOHNIndividualCORPORATE DIRECTORsince 07/01/2021
HOFF, JOSEPHIndividualCORPORATE OFFICERsince 07/18/2017
MITCHELL, CYNTHIAIndividualCORPORATE OFFICERsince 04/06/2016
SHANNON, CHARLESIndividualCORPORATE OFFICERsince 03/15/2012

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.

$17.2M
Net patient revenuemost recent cost report
+7.0%
Operating marginrevenue minus expenses
$1.6M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 24%Other / private 34%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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

$379per resident / day
operating cost
$11,510per month
≈ monthly operating cost
$407per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Virginia
$10,250/mo
Nursing home (semi-private)
$11,680/mo
Nursing home (private)
$6,945/mo
Assisted living

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 495421. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-25, 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.

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