Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Health And Rehab Center - South during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple complex diagnoses received several incorrect doses of Morphine Sulfate after staff failed to verify the medication label against the physician's order. The pharmacy dispensed and labeled the medication at the wrong concentration, and nursing staff administered the drug based on this incorrect information, contrary to facility policy requiring verification of medication details prior to administration.
Facility staff failed to follow professional standards for medication administration when a resident with severe cognitive impairment and multiple diagnoses received incorrect doses of morphine sulfate. Staff did not verify the medication label against the physician's order, leading to administration errors due to discrepancies in concentration and dosing instructions between the pharmacy label and the original order.
The facility failed to ensure the availability of medications for four residents, impacting their treatment for conditions such as rheumatoid arthritis, bipolar disorder, and hyperlipidemia. LPNs discovered the absence of medications like Tylenol, Thiamine, Valium, and Atorvastatin during medication passes, and the emergency supply did not include these medications. This deficiency was discussed with the facility's administration.
A resident with severe cognitive and physical impairments did not receive documented ADL care, including grooming and personal hygiene, due to blank spaces in the ADL documentation for several shifts. The facility's ADON and DON acknowledged the lack of evidence for care provision, and staff confirmed that blank spaces indicated uncharted care.
A resident with a history of traumatic subdural hematoma and asthma was allowed to self-administer inhalers without a completed self-administration assessment, contrary to facility policy. Despite being cognitively intact, the resident's care plan lacked a self-administration plan, and staff interviews revealed inconsistencies in the understanding of the resident's medication management.
A resident with obstructive sleep apnea was observed using a CPAP machine, but the facility failed to accurately code this in the MDS assessment. The resident's care plan and physician's order summary also lacked documentation for CPAP use. An LPN confirmed the resident's regular use of the CPAP, and the MDS coordinator acknowledged the oversight. The deficiency was discussed with facility administration.
The facility failed to develop comprehensive care plans for two residents, one requiring a CPAP machine and another for self-administration of medications. Despite observations and physician orders, these needs were not reflected in their care plans, contrary to facility policy.
A resident with complex medical conditions, including heart failure and hypertension, was administered Metoprolol outside of physician-ordered parameters in a LTC facility. The medication was given despite orders to hold it if the resident's diastolic blood pressure was 60 or less. This was confirmed by an LPN during a surveyor's review, highlighting a failure to follow the facility's medication administration policy.
A facility failed to adequately monitor a resident receiving multiple psychotropic medications, including Abilify, Sertraline, Trazodone, and Lorazepam. Despite the facility's policy requiring behavior monitoring, no documentation was found on the MAR for April 2024, and progress notes lacked consistent behavior monitoring. The Assistant Director of Nursing confirmed the expectation for such monitoring, but it was not located, leading to a deficiency identified during a survey.
A resident with post-procedural hypothyroidism did not receive Levothyroxine as ordered due to unavailability on the medication cart. Despite the facility's policy to check the STAT medication list and notify the physician, the 75 mcg dosage was not listed, leading to missed doses. The issue was discussed with the facility's administration and nursing leadership.
The facility staff failed to maintain complete and accurate clinical records for three residents, resulting in deficiencies. A resident's allergy to ampicillin/sulbactam was not documented, and their initial skin assessment missed areas with a rash. Another resident's DDNR form was incomplete, lacking necessary certifications. Additionally, a third resident's responsible party's decision to decline vaccines was not documented, despite being offered. These issues were discussed with the facility's leadership, but no further information was provided before the survey exit.
A contract staff member failed to perform hand hygiene between residents while providing toenail care, despite changing gloves. This was observed on multiple occasions, violating the facility's infection prevention policy. The issue was discussed with the facility's administration.
Two residents with significant health conditions were not offered pneumococcal vaccines upon admission, despite being eligible and having consented to vaccination. Both residents had previously received a Prevnar13 vaccine but were not offered a PCV20 or PPSV23 vaccine as recommended by CDC guidelines. The facility's policy requires tracking and administering vaccines, yet no evidence was found that these residents were offered the necessary vaccinations.
The facility failed to offer an updated 2023-2024 COVID-19 vaccine to three residents, despite having a policy to provide vaccines weekly. The residents, who were cognitively intact, had previously received COVID-19 vaccines but were not offered the updated version. The DON and IP could not provide evidence of the offer or documentation of contraindications, as required by the facility's policy.
Medication Labeling and Administration Error with Morphine Sulfate
Penalty
Summary
Facility staff failed to ensure that a resident's medication, Morphine Sulfate, was accurately labeled and administered according to physician orders. The resident, who had diagnoses including multiple sclerosis, epilepsy, long-term opiate use, and a history of traumatic brain injury, was severely cognitively impaired and unable to self-advocate. The physician's orders specified Morphine Sulfate Oral Solution at a concentration of 10 mg/5 ml, with various dosing instructions for administration via G-Tube and buccally. However, the pharmacy dispensed Morphine Sulfate at a concentration of 100 mg/5 ml, and the medication bottle, as well as the narcotic control sheet, were labeled with this incorrect concentration and dosing instructions that did not match the original physician order. Nursing staff administered the morphine based on the incorrect label and narcotic control sheet, resulting in the resident receiving multiple incorrect doses. The medication administration record (MAR) did not match the concentration or instructions on the medication bottle or narcotic control sheet. Nurses failed to compare the medication label to the physician's order prior to administration, as required by facility policy. This failure led to the administration of significantly higher doses of morphine than prescribed. The facility's policy required staff to verify the right medication, dosage, time, and route before administration, but this procedure was not followed. The error was discovered after the resident had already received several incorrect doses. The administrator confirmed that the pharmacy had sent a different concentration than ordered, labeled the dosage incorrectly, and that nursing staff did not verify the label against the physician's order before administering the medication.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice for medication administration for a resident with multiple complex diagnoses, including multiple sclerosis, epilepsy, chronic pain, and severe cognitive impairment. The staff did not compare the medication label to the physician's order before administering morphine sulfate, resulting in the resident receiving multiple incorrect doses. The medication administration record (MAR), narcotic control sheet, and the actual medication bottle from the pharmacy contained discrepancies in concentration and dosing instructions, which were not identified by the nursing staff prior to administration. The pharmacy provided a morphine sulfate solution with a different concentration than what was ordered, and the label on the medication bottle instructed a dosage that did not match the physician's order. Nurses administered the medication according to the incorrect label and did not verify the concentration or instructions against the original physician's order, as required by facility policy. The facility's policy clearly stated that staff must check the label to verify the right medication, dosage, time, and route before administration, but this procedure was not followed in this instance. The deficiency was identified through staff interviews, clinical record review, and facility policy review. The administrator confirmed that the error occurred due to both the pharmacy's failure to notify the facility of the concentration change and the nursing staff's failure to adhere to established medication administration protocols. The incident involved the administration of morphine sulfate in incorrect doses to a resident who was severely cognitively impaired and receiving end-of-life care.
Medication Availability Deficiency
Penalty
Summary
The facility staff failed to ensure the availability of medications for four residents, leading to deficiencies in pharmaceutical services. For Resident #57, the staff did not have Tylenol 500 mg available, which was necessary for managing the resident's rheumatoid arthritis pain. During a medication pass, the LPN discovered the medication was not on the cart and attempted to retrieve it from the emergency supply, only to find that the required dosage was unavailable. The staff had to contact the nurse practitioner to obtain a temporary order for a lower dosage. Resident #76 experienced a similar issue with the unavailability of Thiamine, which was prescribed as a daily supplement. The LPN noted the absence of the medication during a medication pass and had to order it from the pharmacy. Despite the order being faxed, the medication was not delivered promptly, and the resident went without the supplement for an extended period. The emergency supply did not include Thiamine, further complicating the situation. For Resident #18, the medications Valium and Fibercon were unavailable, impacting the resident's treatment for muscle relaxation and constipation. The eMAR indicated the medications were not available on specific dates, and the emergency supply did not include these medications. Similarly, Resident #44's medications, Valproic acid and Atorvastatin, were not available, affecting the management of bipolar disorder and hyperlipidemia. The eMAR and nurse's notes confirmed the unavailability of these medications, and the emergency supply did not have them listed.
Failure to Document and Provide ADL Care
Penalty
Summary
The facility staff failed to provide necessary activities of daily living (ADL) care for a resident, specifically in maintaining appropriate grooming, personal, and oral care. The resident, who was part of a sample of 26, had significant medical conditions including hemiplegia, hemiparesis, aphasia, dysphagia, apraxia, lack of coordination, and a history of repeated falls. The resident's cognitive skills were severely impaired, requiring extensive assistance for personal hygiene tasks such as combing hair, brushing teeth, shaving, and washing the face and hands. The care plan indicated a self-care deficit in ADL performance, necessitating extensive assistance from two staff members. Upon reviewing the ADL documentation for the months of September and October 2022, it was found that several shifts were left blank, indicating a lack of documentation on whether the care was provided. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that the blank spaces provided no evidence of care being given. Interviews with a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) confirmed that blank spaces meant the care was not charted, and there was no evidence of care being provided during those shifts. The facility's administration was informed of these documentation gaps, but no further information was provided before the exit conference.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility staff failed to ensure that a resident was clinically assessed for the appropriateness of self-administering medications. The resident, who has a history of traumatic subdural hematoma, quadriplegia, and moderate persistent asthma, was found to be cognitively intact with a mental status score of 15 out of 15. Despite this, the facility did not complete a self-administration of medications assessment for the resident, as required by their policy. The resident's care plan did not include a plan for self-administration of medications, although physician orders allowed for unsupervised self-administration of inhalers for asthma. Interviews with facility staff revealed inconsistencies in the understanding of the resident's self-administration of medications. The unit manager was unaware of the resident self-administering medications, while an LPN confirmed that the resident kept inhalers in their room for self-use, as per the family nurse practitioner's order. The facility's policy mandates a self-administration assessment to be completed before allowing residents to self-administer medications, which was not adhered to in this case. The issue of not completing quarterly assessments was discussed with the facility's administration team.
Inaccurate MDS Assessment for CPAP Use
Penalty
Summary
The facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident #50, who was using a Continuous Positive Airway Pressure (CPAP) machine. The resident's face sheet listed diagnoses including encephalopathy, Parkinson's disease, and obstructive sleep apnea. However, the most recent MDS assessment did not code the use of the CPAP machine, despite the resident being observed with the CPAP mask in place on multiple occasions. Additionally, the resident's comprehensive care plan did not include a plan for the use of CPAP, and the physician's order summary for the month of April did not include an order for CPAP. The surveyor observed the resident using the CPAP machine and confirmed with an LPN that the resident uses the CPAP whenever lying down. The MDS coordinator acknowledged that the use of the CPAP should have been included in the MDS if it was used during the look-back period. The facility's policy on Resident Assessment and Care Planning requires that special treatments or procedures be included in the comprehensive assessment. The deficiency was discussed with the facility's administration, but no further information was provided before the surveyor's exit.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to develop a comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #50, who has diagnoses including encephalopathy, Parkinson's disease, and obstructive sleep apnea, the staff did not create a care plan for the use of a CPAP machine. Despite the resident being observed using the CPAP machine, there was no physician's order for it, and it was not included in the resident's comprehensive care plan. The MDS coordinator confirmed that the use of CPAP should have been included in the care plan. For Resident #56, who is cognitively intact and has diagnoses including traumatic subdural hematoma, quadriplegia, and asthma, the facility staff failed to develop a care plan for self-administration of medications. The resident's physician's order summary included orders for unsupervised self-administration of inhalers, but the comprehensive care plan did not reflect this. The unit manager and LPN provided conflicting information about the resident's self-administration of medications, and the MDS coordinator acknowledged that it should have been care planned. The facility's policy requires a comprehensive care plan to be developed within seven days of the comprehensive assessment, including measurable objectives and timetables to meet the resident's needs. However, the facility did not adhere to this policy for the two residents, resulting in the deficiencies noted by the surveyor.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medications, specifically the blood pressure medication Metoprolol. The medication was administered outside of the physician-ordered parameters, which specified that it should be held if the resident's diastolic blood pressure (DBP) was 60 or less. Despite this order, the medication was administered on multiple occasions when the resident's DBP was at or below 60, including instances with a DBP of 58 and 60. The resident involved had a complex medical history, including diagnoses of diastolic heart failure, hypertensive heart disease, Alzheimer's Dementia with anxiety, atrial fibrillation (AFIB), and hypertension (HTN). The resident was also noted to be severely cognitively impaired. The facility's policy on administering medications stated that medications should be administered safely, timely, and as prescribed. However, the failure to adhere to the physician's order for Metoprolol administration was acknowledged by a licensed practical nurse (LPN) during the surveyor's review.
Failure to Monitor Resident on Psychotropic Medications
Penalty
Summary
The facility staff failed to provide adequate monitoring for a resident receiving psychotropic medications, leading to a deficiency identified during a survey. The resident, who had diagnoses including anxiety, depression, history of stroke, diabetes, and obstructive sleep apnea, was prescribed multiple psychotropic medications such as Abilify, Sertraline, Trazodone, and Lorazepam. Despite these prescriptions, there was no behavior monitoring documented on the Medication Administration Record (MAR) for the month of April 2024, and progress notes did not indicate consistent monitoring of the resident's behaviors. The Assistant Director of Nursing confirmed that behavior monitoring should be documented on the MAR, but they were unable to locate any such documentation for the resident. The facility's Behavior Monitoring Policy, dated May 2017, requires documentation of behaviors, non-pharmacological interventions, and side effects of medications. However, the facility staff did not adhere to this policy, as evidenced by the lack of behavior monitoring for the resident on multiple psychotropic medications. This issue was discussed with the facility's administration, but no further information was provided to the survey team before the exit conference.
Failure to Administer Levothyroxine as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors by not administering Levothyroxine as per the physician's order. The resident, who is cognitively intact with a mental status score of 15 out of 15, has a diagnosis of post-procedural hypothyroidism among other health conditions. The physician's order required the administration of Levothyroxine Sodium Oral Tablet 75 mcg daily until a specified date, followed by 50 mcg daily thereafter. However, the medication administration record indicated that on two occasions, the medication was not administered because it was not available on the medication cart. The facility's policy for handling unavailable medications requires staff to check the STAT medication list and notify the physician if the medication is unavailable. Although Levothyroxine 50 mcg was available in the STAT/Emergency Medication Cart, the 75 mcg dosage was not listed. The failure to administer the medication as ordered was discussed with the facility's administration and nursing leadership, but no further information was provided before the surveyor's exit.
Deficiencies in Clinical Record Documentation
Penalty
Summary
The facility staff failed to ensure complete and accurate clinical records for three residents, leading to deficiencies in documentation and communication. For one resident, the medication allergy section of the electronic health record was incomplete, missing a critical allergy to ampicillin/sulbactam, which had previously caused a possible anaphylactic reaction. Additionally, the initial skin assessment for this resident did not document areas affected by a rash, despite having a treatment order for a topical cream. This oversight was acknowledged by the Assistant Director of Nursing, who noted that the rash was present upon admission but not recorded in the initial assessment. Another resident's clinical record contained an incomplete Virginia Department of Health Durable Do Not Resuscitate (DDNR) form. Although the resident's face sheet and care plan indicated a DNR order, the DDNR form lacked necessary certifications and checkboxes, leaving the document incomplete. This issue was discussed with the facility's administration, but no further information was provided before the survey exit. For a third resident, the facility staff failed to document the responsible party's decision to decline influenza, pneumococcal, and updated COVID-19 vaccines. Despite the Unit Manager offering these vaccines to the resident's responsible party, the refusal was not recorded in the clinical record, contrary to the facility's policy on immunization documentation. This lapse was confirmed by the Infection Preventionist and the Unit Manager, and the concern was raised with the facility's leadership team during the survey process.
Failure in Hand Hygiene During Resident Care
Penalty
Summary
The facility staff failed to ensure proper hand hygiene practices were followed by a contract staff member, identified as SM #20, during the provision of toenail care to multiple residents. According to the facility's handwashing policy, hand hygiene is crucial in preventing the spread of infections and should be performed before and after contact with residents. Despite this policy, SM #20 was observed changing gloves between residents but did not perform hand hygiene, such as using alcohol-based hand rubs or washing hands with soap and water, as required. The deficiency was observed on multiple occasions on the same day, where SM #20 provided toenail care to three different residents consecutively without performing hand hygiene between each resident. This was confirmed during an interview with SM #20, who acknowledged changing gloves but admitted to not performing hand hygiene. The issue was discussed with the facility's administration, including the Administrator, Director of Nursing, Assistant Director of Nursing, and Vice-President of Operations, highlighting the failure to adhere to the facility's infection prevention and control program.
Failure to Offer Pneumococcal Vaccines to Eligible Residents
Penalty
Summary
The facility staff failed to offer pneumococcal vaccines to two residents, despite their eligibility and documented medical conditions that warranted such vaccinations. Resident #24, who was cognitively intact, had a history of receiving a Prevnar13 vaccine in 2016 but had not been offered a PCV20 or PPSV23 vaccine upon admission. The resident's medical record indicated several serious health conditions, including osteomyelitis, atrial fibrillation, and aortic aneurysm, which increased the need for updated pneumococcal vaccination. Despite the resident's consent form indicating uncertainty about their vaccination status, the facility did not provide evidence of offering the necessary vaccines as per CDC guidelines. Similarly, Resident #76, also cognitively intact, had received a Prevnar13 vaccine in 2016 but had not been offered a PCV20 or PPSV23 vaccine upon admission. This resident's medical history included chronic respiratory failure, COPD, and heart disease, conditions that necessitate pneumococcal vaccination according to CDC recommendations. The resident's consent form also showed uncertainty about their vaccination status, yet the facility failed to document any offer of the required vaccines. The Infection Preventionist acknowledged the oversight, and the Director of Nursing mentioned past issues with insurance coverage for the vaccines, although doses were available at the time of the survey. The facility's policy on immunizations, which was reviewed and revised in January 2024, mandates tracking and administering vaccines per CDC guidelines. However, the surveyors found no evidence that the facility adhered to this policy for the two residents in question. The survey team discussed these deficiencies with the facility's leadership, but no additional information or corrective actions were provided before the exit conference.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility staff failed to offer an updated 2023-2024 formula COVID-19 vaccine to three residents, despite having a policy in place to provide such vaccines weekly. Resident #3, who was cognitively intact with a BIMS score of 13 out of 15, had a history of receiving previous COVID-19 vaccines but was not offered the updated vaccine. The Director of Nursing (DON) and Infection Preventionist (IP) could not provide evidence of the offer being made, as required by the facility's policy. Resident #24, also cognitively intact with a BIMS score of 15 out of 15, was not offered the updated COVID-19 vaccine. The DON mentioned that the resident's physician did not want the vaccine administered while the resident was on IV antibiotics, but there was no documentation of contraindications or evidence of the vaccine being offered. The facility's policy mandates documentation of acceptance, refusal, or medical contraindications, which was not adhered to in this case. Similarly, Resident #75, with a BIMS score of 15 out of 15, was not offered the updated vaccine despite having received previous doses. The facility's policy requires that vaccination status be determined at admission and that a master list of residents receiving vaccinations be maintained. However, the DON and IP were unable to provide evidence of compliance with these procedures for Resident #75.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roanoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pheasant Ridge Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 7 | 0 |
| South Roanoke Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 0 | 0 |
| Raleigh Court Health And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 4.4 mi | ★★★★★ | 0 | 0 |
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