C+
68/100SOUTH ROANOKE NURSING AND REHABILITATION Inspection Report, Violations & Safety Grade (ROANOKE, Virginia)
3823 FRANKLIN RD, SW, ROANOKE, Virginia 24014
Phone: 5403444325
CMS Overall:3/5
Overview & Bed Count
Certified Beds
98
Avg Residents/Day
94.6
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Roanoke City
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health2/5
Staffing3/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Virginia Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.45 | 0.71 | -0.26 |
| Total Nurse Hours per Resident per Day | 3.06 | 3.88 | -0.82 |
| CMS Staffing Rating | 3/5 | 2.5/5 | - |
| Nursing Staff Turnover | 35.4% | 47.5% | - |
Health Citation History
39 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-04-24 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-04-24 | Environmental Deficiencies | Have enough backup water supply for essential areas of the nursing home. | F – Moderate Harm Potential |
| 2025-04-24 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2025-04-24 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2025-04-24 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2025-04-24 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2025-04-24 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2025-04-24 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-04-24 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-04-24 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-04-24 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2022-03-24 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2022-03-24 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | F – Moderate Harm Potential |
| 2022-03-24 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2022-03-24 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2022-03-24 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2022-03-24 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2022-03-24 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2022-03-24 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2022-03-24 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2022-03-24 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2022-03-24 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2022-03-24 | Infection Control Deficiencies | Perform COVID19 testing on residents and staff. | D – Moderate Harm Potential |
| 2022-03-24 | Infection Control Deficiencies | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | D – Moderate Harm Potential |
| 2022-03-24 | Infection Control Deficiencies | Ensure staff are vaccinated for COVID-19 | D – Moderate Harm Potential |
| 2019-07-09 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2019-07-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2019-07-09 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E – Moderate Harm Potential |
| 2019-07-09 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2019-07-09 | Resident Rights Deficiencies | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | D – Moderate Harm Potential |
| 2019-07-09 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2019-07-09 | Resident Rights Deficiencies | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D – Moderate Harm Potential |
| 2019-07-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2019-07-09 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2019-07-09 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2019-07-09 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2019-07-09 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2019-07-09 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2019-07-09 | Environmental Deficiencies | Have policies on smoking. | D – Moderate Harm Potential |
Fire Safety Citation History
20 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-04-24 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2025-04-24 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | F – Moderate Harm Potential |
| 2025-04-24 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-04-24 | Emergency Preparedness Deficiencies | Address patient/client population and determine types of services needed. | E – Moderate Harm Potential |
| 2025-04-24 | Emergency Preparedness Deficiencies | Provide emergency officials' contact information. | E – Moderate Harm Potential |
| 2022-03-24 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2022-03-24 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2019-07-09 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | F – Moderate Harm Potential |
| 2019-07-09 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Address patient/client population and determine types of services needed. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Establish policies and procedures for sheltering. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Establish policies and procedures for medical documentation. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Establish policies and procedures for volunteers. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Establish methods for sharing information. | D – Moderate Harm Potential |
| 2019-07-09 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the ROANOKE area at no cost.
Find Safe, Vetted Facilities Near ROANOKE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.