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 South Roanoke Nursing And Rehabilitation during CMS and state inspections, most recent first.
A food service aide with visible facial hair was observed preparing food without a beard net, in violation of facility policy requiring hair restraints during food preparation. The acting director of food and nutrition was present and confirmed the requirement for beard coverage.
Facility staff did not have written procedures to ensure the availability of both drinkable and non-drinkable water in the event of a loss of normal water supply. The Administrator described a verbal plan for water provision, but this was not documented, and emergency water storage was insufficient. The agreement with a water delivery company did not guarantee supply during high demand and did not address non-drinkable water needs.
Staff failed to accurately complete MDS assessments for several residents, including not documenting PRN pain medication use, unplanned weight loss, hospice care, and functional limitations, as well as incorrectly coding restraint use. These errors were identified through record review and staff interviews, revealing discrepancies between clinical documentation and MDS coding.
Facility staff did not consistently develop or implement care plans that reflected residents' documented preferences, such as declining oral suction and oxygen, nor did they ensure required safety interventions like Dycem for fall prevention or two-person assist for mechanical lift transfers were followed. These deficiencies affected residents with varying cognitive abilities and medical complexities, resulting in unmet needs and unaddressed safety measures.
Facility staff did not document required discussions or education with residents or their representatives regarding refusal of treatments such as oral suction and oxygen, as indicated on advance directive forms. Additionally, staff failed to complete advance directive forms according to instructions, using checkmarks or Xs instead of initials for 21 residents.
Facility staff did not provide written notification of the reason for transfer or discharge to a resident with severe cognitive impairment and their representative prior to a hospital transfer, as required. Documentation confirming that the notification was given could not be located when requested by surveyors.
Facility staff did not accurately identify or assess a significant change in a resident's condition, specifically failing to document a 6.1% unplanned weight loss in the MDS assessment. Despite clinical records noting the weight loss, the MDS was incorrectly coded, and the issue was confirmed during staff interviews and record review.
A resident with severe cognitive and physical impairments, dependent on staff for transfers, was transferred by a CNA using a mechanical lift without a second staff member and with the wrong size lift pad. This failure to follow the care plan and facility policy resulted in the resident slipping from the lift pad and falling to the floor.
Facility staff did not perform or document neuro-checks and vital signs as ordered by a medical provider for a resident with severe cognitive impairment after a fall. The required assessments were missed during one interval, with staff noting the resident was sleeping, and no assessment data was available for that time.
Staff failed to provide adequate supervision and appropriate assistive devices for two residents with significant cognitive and physical impairments. One resident was transferred using an incorrectly sized lift pad and without the required second staff member, resulting in a fall, while another resident did not have the prescribed Dycem non-slip material in the wheelchair and was observed transferring independently despite being care planned for assistance.
Staff did not consistently provide or document oxygen therapy as ordered for a resident with advanced respiratory conditions. The resident's oxygen was administered at varying flow rates, and staff followed hospice instructions to titrate oxygen without ensuring proper documentation in the clinical record. There were also gaps in recording oxygen usage and flow rates, leading to a deficiency in respiratory care.
Failure to Ensure Consistent Use of Beard Nets During Food Preparation
Penalty
Summary
Facility staff failed to consistently prevent hair from contacting food in the kitchen, as observed during food preparation. Specifically, a food service aide with visible facial hair was seen preparing residents' food trays without wearing a beard net, despite the presence of the acting director of food and nutrition. When questioned, the director acknowledged that the aide should have had their facial hair covered and instructed the employee to apply a beard net at that time. The facility's policy on employee hygiene and sanitary practices requires that hair nets or beard restraints be worn when cooking, preparing, or assembling food to prevent hair from contacting exposed food, clean equipment, utensils, and linens. The deficiency was identified through direct observation and confirmed by staff interviews and review of facility policy documents. No information about residents' medical history or condition was included in the report.
Lack of Written Procedures for Emergency Water Supply
Penalty
Summary
Facility staff failed to develop and maintain written procedures to ensure the availability of water in the event of a loss of the normal water supply. During the survey, it was found that there were no documented processes addressing both drinkable and non-drinkable water needs for the facility. The Administrator verbally reported a plan to provide 64 ounces of water per day for three days for all residents and staff, but this plan was not documented. Observations revealed that the facility's emergency water storage consisted of only 60 gallons, and while there was an agreement with a water delivery company, the documentation from the company did not guarantee supply during high demand and did not address non-drinkable water needs. The surveyor reviewed the facility's emergency preparedness program and found it lacked written policies detailing how water needs would be met during a water outage. The documentation provided by the water delivery company only estimated purified drinking water needs and did not include recommendations for non-drinkable water. During a meeting with facility leadership, the absence of a written process for both drinkable and non-drinkable water provision in the event of a water supply loss was discussed.
Inaccurate MDS Assessments for Pain Management, Weight Loss, Hospice, Restraint, and Range of Motion
Penalty
Summary
Facility staff failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents, resulting in several deficiencies. For one resident with multiple chronic conditions and severe cognitive impairment, staff did not accurately code the administration of PRN pain medication and failed to document a significant unplanned weight loss on the MDS, despite clear evidence in the medical record and medication administration records. Another resident receiving hospice care was not coded as such on the admission MDS, even though provider orders and the care plan indicated active hospice services. Additionally, a resident was incorrectly coded as using a limb restraint on a quarterly MDS assessment, although no restraint was observed and staff confirmed this was an error. In another case, two MDS assessments for a resident with severe cognitive impairment inaccurately documented functional limitations in lower extremity range of motion, which was inconsistent with other assessments and not supported by clinical findings. These deficiencies were identified through review of clinical records, medication administration records, and staff interviews. The surveyors found that the facility staff did not follow the Centers for Medicare & Medicaid Services Resident Assessment Instrument (RAI) guidelines for accurate MDS coding, leading to discrepancies between the residents' actual clinical status and what was documented in the MDS assessments.
Failure to Implement Comprehensive, Person-Centered Care Plans and Interventions
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans that addressed residents' specific preferences and needs, as documented in their advance directives and clinical records. Several residents had clearly stated wishes to decline certain treatments, such as oral suctioning and oxygen, particularly in end-of-life care situations. Despite these documented preferences, the care plans for these residents did not include interventions reflecting their choices. For example, multiple residents with advance directives explicitly refusing oral suction and oxygen did not have these preferences incorporated into their care plans, even though their cognitive status and ability to participate in care planning varied from severely impaired to cognitively intact. In addition to failures in care planning related to advance directives, the facility did not ensure that specific safety interventions were implemented as outlined in residents' care plans. One resident, identified as high risk for falls, had an intervention for Dycem (a non-slip material) to be used in their wheelchair, but repeated observations showed the Dycem was not present. Staff were unaware of the missing intervention and speculated that the resident may have been removing it, but no alternative intervention was documented or implemented at the time of the survey. Another resident, dependent on staff for transfers and requiring a two-person assist with a mechanical lift, experienced a fall during a transfer when only one staff member was present. The care plan clearly stated the need for two staff during mechanical lift transfers, and facility policy reinforced this requirement. The staff member involved admitted to performing the transfer alone due to perceived staffing shortages, which was contradicted by staffing records. These failures demonstrate a lack of adherence to individualized care plans and facility policies, resulting in unmet resident needs and unaddressed safety risks.
Failure to Document Advance Directive Discussions and Properly Complete Forms
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for 21 of 24 sampled residents, specifically regarding documentation of advance directives and related communications. In multiple cases, staff did not document verbal communication with residents or their representatives about the reasons for refusing treatments such as oral suction and oxygen, as indicated on advance directive forms. Additionally, there was no documentation that education was provided to residents or their representatives about the consequences or potential outcomes of refusing these treatments, despite facility policy requiring such documentation. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, had an advance directive indicating refusal of oral suction and oxygen. However, there was no evidence in the clinical record of staff assessment or documentation of the reasons for this refusal, nor of any education provided to the resident or representative about the implications of these choices. Similar deficiencies were found for other residents, including those who were cognitively intact, where staff failed to document the required discussions and education related to advance directive decisions. Furthermore, the facility staff did not ensure that advance directive forms were completed according to the form's instructions. Instead of having the individual providing the information initial the desired areas, staff marked the forms with checkmarks or Xs. This failure to follow documentation procedures was identified for 21 residents. These deficiencies were confirmed through interviews with residents, family members, and staff, as well as reviews of clinical records and facility policies.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
Facility staff failed to provide written notification of the reason for transfer or discharge to a resident and the resident's representative prior to a hospital transfer. The deficiency was identified through staff interviews, clinical record review, and facility document review, which revealed that no evidence of written notification was present for the transfer that occurred on 4/3/25. When requested by the surveyor, administrative staff confirmed that they could not locate documentation showing that the required notification had been given. The resident involved had multiple diagnoses, including osteoarthritis, Alzheimer's disease, hypertension, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease stage 3, and a history of digestive system surgery. The most recent assessment indicated severe cognitive impairment, with a BIMS score of 6 out of 15. Despite these factors, there was no documentation that the resident or their representative received written notification regarding the transfer, as required.
Failure to Identify and Assess Significant Weight Loss
Penalty
Summary
Facility staff failed to accurately identify and assess a significant change in a resident's physical condition using the Resident Assessment Instrument (RAI) process. Specifically, a resident with multiple diagnoses, including osteoarthritis, Alzheimer's disease, hypertension, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease stage 3, and a history of digestive system surgery, experienced a 6.1% weight loss over thirty days. Despite this, the comprehensive Minimum Data Set (MDS) assessment did not reflect the significant weight loss, as Section K0300 was coded to indicate no weight loss of 5% or more in the last month. A nurse's progress note documented the significant weight loss, but this information was not incorporated into the MDS assessment. During a staff interview, an LPN acknowledged that the MDS should have been coded as a significant change assessment due to the unplanned weight loss and that the weight loss should have been recorded. The deficiency was identified through clinical record review, staff interview, and facility document review, and was discussed with facility leadership prior to survey exit.
Failure to Follow Mechanical Lift Protocols Resulting in Resident Fall
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for one resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, dementia, generalized muscle weakness, and a history of falls, was assessed as severely cognitively impaired and dependent on staff for transfers. The resident's care plan specified that transfers should be performed using a mechanical lift with the assistance of two staff members and the correct size lift pad. However, during a transfer from chair to bed, a CNA used a lift pad with four loops instead of the required medium/purple six-loop pad and performed the transfer alone, contrary to facility policy and the resident's care plan. As a result of these actions, the resident slipped through the lift pad and fell to the floor. Staff interviews confirmed that the CNA did not wait for a second staff member and used the incorrect lift pad size. Documentation and staff statements indicated that the correct lift pad size was listed at the nurse's desk and that the unit was not short-staffed at the time of the incident. Facility policy required two staff for mechanical lift transfers and proper sling sizing, but these procedures were not followed, leading to the resident's fall.
Failure to Complete and Document Ordered Neuro-Checks and Vital Signs
Penalty
Summary
Facility staff failed to perform and document neuro-checks and vital signs as ordered by a medical provider for one resident following a fall. The resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, had provider orders for neuro-checks and vital signs every four hours. Documentation on the medication administration record (MAR) showed that these assessments were not completed at the 4:00 a.m. interval, with staff noting the resident was sleeping instead. No assessment findings or data for this missed check were found or provided to the surveyor. Facility policy required that neuro-checks be performed and documented as ordered, including specific neurological and vital sign assessments. During interviews, the Director of Nursing confirmed that the resident should have been woken up to complete the required assessments. The failure to complete and document the neuro-checks and vital signs as ordered was discussed with facility leadership during surveyor meetings.
Failure to Prevent Accidents Due to Inadequate Supervision and Assistive Devices
Penalty
Summary
Facility staff failed to ensure that two residents received appropriate assistance and assistive devices to prevent accidents. For one resident with hemiplegia, dementia, generalized muscle weakness, and a history of falls, staff used an incorrectly sized mechanical lift pad and performed a transfer with only one staff member instead of the required two. During the transfer, the resident slipped from the lift pad and fell to the floor. The staff member then moved the resident from the floor to the bed before a nurse could assess for injuries, contrary to facility policy. The resident was dependent on staff for transfers and was care planned for two-person assistance with a mechanical lift and the correct size lift pad, but these interventions were not followed at the time of the incident. Another resident, who had diagnoses including traumatic subdural hemorrhage, Parkinsonism, dementia, and repeated falls, did not have Dycem non-slip material in the wheelchair as specified in the care plan. This resident was severely cognitively impaired, dependent on staff for transfers, and had a recent history of multiple falls. During multiple observations, the resident was seen transferring independently and walking without assistance, and the required Dycem was not present in the wheelchair. Staff were unaware of the missing Dycem and could not provide an explanation at the time of the survey. Facility policies required at least two staff for mechanical lift transfers and the use of properly sized lift pads, as well as individualized fall prevention interventions. In both cases, staff did not follow established protocols and care plan interventions, resulting in preventable incidents involving residents at high risk for falls and injury.
Failure to Consistently Provide and Document Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to consistently provide and document respiratory care for a resident with multiple respiratory diagnoses, including lung cancer, COPD, emphysema, and respiratory failure. The resident was cognitively intact and had a physician's order for oxygen at 8 LPM via nasal cannula, with instructions to remove for ADLs. The care plan and electronic medication administration record reflected this order. However, observations revealed the oxygen concentrator was set at varying levels (3, 5, and 6 LPM) rather than the prescribed 8 LPM, and staff reported following hospice guidance to titrate oxygen down, though no corresponding order was found in the clinical record at the time of survey. Documentation in the resident's clinical record was inconsistent, with oxygen flow rates and usage not always recorded, and gaps in data for several weeks. Hospice notes indicated attempts to decrease oxygen, but the official order to titrate oxygen was not entered into the facility's record until after the surveyor's inquiry. Staff interviews revealed confusion about the current orders, with reliance on verbal or faxed instructions from hospice that were not properly documented. This lack of consistent documentation and adherence to physician and hospice orders led to the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.9 mi | ★★★★★ | 7 | 0 |
| Raleigh Court Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center - South | 2.2 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 2.2 mi | ★★★★★ | 0 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.