Below 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 Star City Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility staff failed to follow the posted menus and serve correct portions during meals. During a midday meal, dinner rolls were omitted from trays, and peas and carrots were served instead of oriental vegetables without approval. In the evening, a dietary aide used a scoop that served 2.75 ounces of pudding instead of the required four ounces. These actions were contrary to the facility's policy requiring adherence to menus and proper portion sizes.
The facility staff failed to ensure food was served at a safe and appetizing temperature. Observations revealed that dietary staff did not document food temperatures, and upon checking, some food items were below the desired temperature. A review of food temperature logs showed incomplete documentation, contrary to the facility's policy requiring daily temperature checks and records.
The facility failed to maintain food safety and sanitation standards across multiple units. On the Juniper unit, the refrigerator and microwave were unclean, with expired and unlabeled food items, and the area was infested with gnats. The Emerald unit had similar issues, with a non-operational refrigerator and improperly stored food. In the dietary department, a staff member was observed without a beard restraint, and handwashing sinks dispensed only cool water, violating hygiene policies.
The facility's Juniper unit failed to maintain an effective pest control program, resulting in a gnat infestation. Surveyors observed numerous gnats in the kitchen area, with residents and staff reporting worsening conditions. The Maintenance Director acknowledged the issue, attributing it to trash disposal problems, but had not discussed it with the pest control company. Despite monthly pest control visits, the Regional Director of Operations was unaware of the problem until the survey.
A resident was readmitted to the facility after being discharged with a return not anticipated, but the staff failed to complete a comprehensive admission assessment in a timely manner. The MDS assessment, with an ARD of 10/18/24, was not completed until 11/6/24. A RN confirmed the delay and stated the assessment could be reopened and completed, but it would be late. The resident was assessed with intact cognition, scoring 15 out of 15 on the BIMS.
A facility failed to complete a quarterly MDS assessment within the required time limits for a resident. The assessment, with an ARD of 10/18/24, was completed late on 11/6/24. An RN confirmed the delay during an interview, and the issue was discussed with the facility's administration.
The facility failed to follow medical orders for two residents. One resident did not receive medication at the prescribed time before wound care, and another missed several speech therapy appointments due to transportation issues. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed expired and improperly stored perishable food items in the main kitchen and unit kitchen service areas. The Dietary Manager and Administrator acknowledged the issues, noting recent staffing changes.
The facility staff failed to provide the 2023-2024 COVID-19 vaccine to three residents who had consented to receive it. The plan to have a community pharmacy conduct a vaccine clinic fell through, and no immediate alternative plan was made. The facility was also undergoing a corporate change, contributing to the delay in vaccine administration.
A resident with intact cognition was unable to access their personal funds to make a desired purchase due to the facility's policy requiring 24-hour notice for large withdrawals. The facility's Administrator confirmed the issue, which occurred before a change of ownership.
The facility staff failed to provide a resident's responsible party and the ombudsman with written information related to a discharge/transfer. A resident with cognitive impairments was transferred to a local emergency department due to altered mental status, but no written transfer notice was provided to the resident's representative. Additionally, the facility had not been communicating discharges to the ombudsman, a failure identified in September 2023.
The facility staff failed to provide a resident's responsible party with written bed hold information when the resident was admitted to a local hospital. Despite the facility's policy, no evidence was found that such information was given to the resident's representative, as confirmed by the Director of Nursing and Administrator.
The facility staff failed to update a resident's care plan to include necessary isolation precautions for ESBL in the urine, despite physician's orders and visible signs of contact precautions. The DON confirmed the omission during a survey.
Facility staff failed to provide pressure ulcer dressing changes as ordered for a resident with a stage 3 sacral ulcer. The resident reported missed wound care on multiple occasions, and clinical records confirmed missed treatments and false documentation. The RNCC acknowledged the issues, and the DON noted ongoing investigations.
The facility staff failed to ensure that two residents' drug regimens were free from unnecessary medications and did not consistently monitor symptoms related to antidepressant use. One resident had an unjustified dosage increase, and both residents lacked comprehensive symptom monitoring for depression.
The facility staff failed to maintain a medication error rate below 5%, resulting in a rate of 5.41%. An LPN did not administer Aspirin as ordered and applied an incorrect dosage of a Nicotine Patch to a resident with multiple diagnoses, including COPD and hypertension. The errors were acknowledged by the LPN, and the facility's medication administration policy was reviewed.
Failure to Follow Menus and Serve Correct Portions
Penalty
Summary
The facility staff failed to consistently follow the menus for resident meals, as observed during a survey. On one occasion, during the midday meal, the dietary staff did not include a dinner roll on the food trays sent to the resident units, despite it being listed on the menu. Three carts of food trays were sent without the dinner rolls, which were later baked and added to the remaining trays. Additionally, the menu specified oriental vegetables, but peas and carrots were served instead. The Dietary Manager confirmed that mixed vegetables should have been used and that the cook did not get approval for the substitution. Further deficiencies were noted during the evening meal when the facility staff failed to provide the correct serving size of pudding. A dietary aide used a scoop with a blue handle to serve pudding, which was supposed to be a four-ounce serving according to the menu. However, the dietary aide was unable to identify the size of the scoop, and it was later determined by the Dietary Manager that the scoop used was only 2.75 ounces. This was confirmed by measuring the scoop's capacity and comparing it with another measuring device. The facility's policy requires that menus meet nutritional needs and be followed as posted, with any deviations or substitutions approved and of comparable nutritive value.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility staff failed to ensure that food was served at a safe and appetizing temperature, as observed by the surveyor on November 6, 2024. During the observation, dietary staff were seen plating food from the steam table without documenting the food temperatures for the meal. The Dietary Manager confirmed the lack of documentation and was responsible for checking the temperatures. Upon checking, the pureed peas and chicken were found to be below the desired temperatures, at 93 and 96 degrees Fahrenheit, respectively, prompting reheating of the food items. Further review of the facility's food temperature logs revealed significant gaps in documentation. No food temperatures had been recorded for November 2024, and the logs for October 2024 were incomplete, with entries missing for several days and meals. The facility's policy mandates daily recording of food temperatures to ensure proper serving temperatures, with hot foods held at 135 degrees Fahrenheit or greater. The survey team discussed these deficiencies with the facility's administration and regional directors, highlighting the failure to check, document, and maintain food temperatures as per the facility's policy.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility staff failed to store, prepare, and serve food in accordance with professional standards for food service safety across multiple resident care units and the facility kitchen. On the Juniper resident care unit, the refrigerator and microwave were not maintained in a clean and sanitary condition. The refrigerator contained unlabeled and undated perishable food items, some of which were expired or showed signs of mold. Additionally, the kitchen area was infested with small, black, gnat-sized flying insects. The facility's temperature logs for the refrigerator were incomplete, with the last recorded temperature documented weeks prior to the survey. On the Emerald resident care unit, similar issues were observed. The microwave was heavily soiled, and a non-operational refrigerator contained a half-full container of Ranch salad dressing. A container of sauced noodles and shrimp was left on the counter for several hours, accessible to residents, indicating a failure to properly store prepared food. The facility's policies on monitoring cooler/freezer temperatures and date marking for food safety were not adhered to, as evidenced by the lack of temperature logs and improperly labeled food items. Additional deficiencies were noted in the facility's dietary department. A dietary aide was observed working without a beard restraint, contrary to the facility's personal hygiene policy. Two of the three handwashing sinks in the dietary department were dispensing only cool water, which was not in compliance with the facility's handwashing guidelines. These issues were discussed with the facility's administration and relevant directors, but no further information regarding corrective actions was presented to the survey team before the exit conference.
Ineffective Pest Control Program on Juniper Unit
Penalty
Summary
The facility staff failed to maintain an effective pest control program on the Juniper resident care unit, leading to the presence of small, black, gnat-sized flying insects. During a survey, a minimum of 20 such insects were observed in the kitchen area, which was separated from the resident dining and living areas by a counter and waist-high gate. The shelf under the unit microwave was found to be soiled with food crumbs and debris. Residents and staff reported that the gnat issue had worsened recently, with one resident noting that the kitchen needed a thorough cleaning and another mentioning that people had been complaining about the gnats for the past two weeks. The facility's Maintenance Director acknowledged awareness of the gnat issue, attributing it to trash inadvertently missing the can and going into a hole beside the water machine. Although a gnat trap was initially placed in the kitchen sink, it was removed due to visitor concerns. The pest control company visited monthly, but the gnat issue had not been discussed with them. Resident Council Minutes from October 2024 also mentioned fruit flies and efforts to address the situation through extermination and cleaning. Despite the facility's pest control service invoices, the Regional Director of Operations was unaware of the gnat problem until the survey and mentioned plans to address it with a special chemical in the drain during the next pest control visit.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility staff failed to complete a comprehensive admission assessment for a resident who was readmitted after being discharged with a return not anticipated. The clinical record review revealed that the Minimum Data Set (MDS) assessment for the resident, with an Assessment Reference Date (ARD) of 10/18/24, was not completed until 11/6/24. This delay in completing the assessment was confirmed by a Registered Nurse (RN) who acknowledged that the assessment had been started but was struck out and not completed in a timely manner. During a meeting with the facility's Administrator, Director of Nursing, and other regional directors, the surveyor discussed the failure to complete the admission/comprehensive MDS assessment upon the resident's readmission. The RN indicated that the assessment could be reopened and completed, but confirmed that it would be completed late. The resident was assessed as having intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was able to make themselves understood and understand others.
Delayed Completion of Quarterly MDS Assessment
Penalty
Summary
The facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time limits for one of the sampled residents. A review of the clinical record for Resident #1 revealed an incomplete quarterly MDS assessment with an assessment reference date (ARD) of 10/18/24, while the previous MDS assessment had an ARD of 7/18/24. The assessment was signed as completed on 11/6/24, indicating a delay. During an interview, Registered Nurse (RN) #1 confirmed that the assessment was late. The survey team discussed this delay with the facility's Administrator, Director of Nursing, and other regional directors.
Failure to Follow Medical Orders for Medication and Therapy
Penalty
Summary
The facility staff failed to adhere to medical provider orders for two residents, leading to deficiencies in care. For Resident #1, the staff did not administer medication according to the prescribed timing. The resident, who was cognitively intact, had a provider order for morphine to be given 15 minutes before wound care. However, the medication was administered over an hour before the wound care was performed, as confirmed by the LPN responsible for the care. This discrepancy was discussed with the facility's administration and nursing leadership. For Resident #3, the facility did not follow the physician's orders for speech therapy services. The resident, who was severely cognitively impaired, had a physician's order for weekly speech therapy sessions. However, the resident missed several appointments due to transportation issues, as confirmed by the unit manager and the scheduler at outpatient therapy. The missed appointments were not initially known to the CNA or LPN involved in the resident's care. The issue was discussed with the facility's administration and nursing leadership, but no further information was provided before the survey exit.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial observation of the facility's main kitchen, the surveyor found a package of sliced ham with a Best By (BB) date of 01/15/24, which was not discarded. Additionally, an open roll of ground beef was improperly stored, leaking red liquid onto a box of ground beef rolls. The Dietary Manager (DM) acknowledged these issues and discarded the items. Similar deficiencies were observed in the unit kitchen service areas, where out-of-date perishable food items were found, including boxes of grits and a can of saute/grill spray with expired BB dates. The DM admitted that these items should have been discarded and mentioned working on a cleaning schedule for dietary staff, having only been in the position for a month. Further observations in the Juniper unit kitchen refrigerator revealed multiple issues, including a box containing various perishable food items that were either uncovered, partially covered, or improperly labeled. These items included sliced turkey lunch meat with white spots, an open package of sliced ham leaking orange fluid, and various cheeses and butter with visible signs of spoilage and contamination. The refrigerator also contained a plastic container with salad dressing and sour cream packets, some of which were past their BB dates. The Dietary Aide (DA#3) present during the observation expressed embarrassment and stated that she would clean out the refrigerator. Additional deficiencies were noted in the Emerald unit kitchen pantry and refrigerator, where expired food items such as buttermilk pancake mix, angel food cake mix, and grits were found. The refrigerator contained a squeezable container of mayonnaise and a package of sealed, sliced turkey with visible white substance around the edges, both past their BB dates. The DM and Administrator (ADM) acknowledged these issues, with the ADM noting that the DM had only been at the facility for a month and that a dietary employee responsible for the Juniper kitchen had recently quit. No further information regarding these concerns was presented to the survey team prior to the exit conference.
Failure to Administer COVID-19 Vaccine to Consenting Residents
Penalty
Summary
The facility staff failed to provide the 2023-2024 COVID-19 vaccine to three residents who had consented to receive it. Despite the CDC's recommendation for everyone aged 5 years and older to get the updated vaccine, the facility did not administer the vaccine to these residents. The clinical records showed that the residents had agreed to receive the vaccine in October 2023, but there was no documentation indicating that they had received it. The infection preventionist (IP) reported that the facility's plan to have a community pharmacy conduct a vaccine clinic fell through due to insufficient interest from residents, and no immediate alternative plan was made to administer the vaccine. The facility was also undergoing a corporate change at the time, which contributed to the delay in vaccine administration. During an interview, the medical director and the director of nursing (DON) acknowledged the failure of the community pharmacy's clinic and the uncertainty caused by the corporate transition. The medical director stated that they were not delaying care intentionally but wanted to ensure it was done correctly. The administrator later confirmed that the facility could purchase the vaccine from their pharmacy and have the staff administer it. The facility's policy on Coronavirus Prevention and Response required that each resident be offered the COVID-19 immunization and that their medical records include documentation of the education provided and the immunization status. However, this policy was not followed for the three residents who had consented to receive the vaccine.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility staff failed to ensure that a resident was able to access their personal funds deposited with the facility. Resident #15, who was assessed as having intact cognition and being able to make themselves understood, reported being unable to obtain money from their personal funds to make a desired purchase in November 2023. The facility's policy required a minimum of 24-hour notice to issue a check for amounts greater than the monthly state allowable amount. Despite this policy, the resident was unable to access sufficient funds for their purchase. The issue was confirmed by the facility's Administrator, who acknowledged that Resident #15 had been unable to make the desired purchase prior to the facility's change of ownership. The surveyor discussed this deficiency with the facility's Administrator and Director of Nursing, highlighting the failure to honor the resident's right to manage their financial affairs as stipulated in the facility's own documentation.
Failure to Provide Written Transfer Notice and Ombudsman Notification
Penalty
Summary
The facility staff failed to provide a resident's responsible party and the ombudsman with written information related to a discharge/transfer for one of the sampled residents. Resident #11, who had cognitive impairments and required assistance with daily activities, was transferred to a local emergency department due to a change in condition, including altered mental status. Despite the medical provider's documentation indicating that the resident's family was aware of the transfer, there was no evidence that written transfer notice/information was provided to the resident's representative. Additionally, the facility's Director of Nursing confirmed that a document addressing the need for an emergent transfer would have been sent with the resident, but no such evidence was found by the surveyor. The facility's Administrator admitted that the facility had not been communicating discharges to the ombudsman, a failure identified in September 2023. The social services department was supposed to submit the facility's discharges to the ombudsman quarterly, but these submissions had not yet started. The survey team discussed the absence of evidence that written information related to the emergent transfer had been provided to the resident's representative and the failure to notify the local ombudsman of the facility's discharges with the facility's Administrator and Director of Nursing.
Failure to Provide Written Bed Hold Information
Penalty
Summary
The facility staff failed to provide a resident's responsible party with written bed hold information when the resident was admitted to a local hospital. Resident #11, who had cognitive impairments and required assistance with daily activities, was transferred to an emergency department and subsequently admitted to the hospital. Despite the facility's policy requiring written notice of bed-hold information to be provided at the time of transfer or within 24 hours in case of emergency transfers, no evidence was found that such information was given to Resident #11's representative. The deficiency was identified during a survey, which included interviews and document reviews. The Director of Nursing (DON) reported that the facility staff would have sent a document addressing bed-holds with the resident at the time of transfer. However, the surveyor found no documentation to support this claim. The absence of evidence was discussed with the facility's Administrator and DON, confirming the failure to comply with the facility's bed-hold policy.
Failure to Revise Care Plan for Isolation Precautions
Penalty
Summary
The facility staff failed to review and revise the comprehensive person-centered care plan for Resident #54 to include the need for isolation precautions. Resident #54 had multiple diagnoses, including Alzheimer's Disease, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, and Hypothyroidism. The resident was severely cognitively impaired, as indicated by a BIMS score of 2 out of 15. On 2/07/24, a surveyor observed a contact precautions isolation sign and PPE present at Resident #54's door. The physician's orders dated 1/30/24 required contact precautions for ESBL in the urine until 2/08/24. However, the comprehensive care plan did not document these contact precautions. The Director of Nursing (DON) confirmed that the care plan did not include the necessary contact precautions after being informed by the surveyor. The facility's policy on Comprehensive Care Plans mandates that the care plan should describe the services required to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Despite this policy, the care plan for Resident #54 was not updated to reflect the need for contact precautions, as confirmed by the DON during the survey team's meeting with the Administrator and DON on 2/13/24.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide pressure ulcer dressing changes as ordered for a resident with a stage 3 sacral ulcer. The resident, who had diagnoses including chronic congestive heart failure, essential hypertension, chronic kidney disease, generalized muscle weakness, clostridium difficile enterocolitis, and a stage 3 sacral ulcer, reported that wound dressings were not changed on two night shifts the previous week. Clinical record review revealed a physician order for specific wound care that was not followed, as evidenced by a blank Treatment Administration Record (TAR) for one of the night shifts. The RNCC confirmed that the dressing change was missed and noted excessive drainage during subsequent dressing changes, which required additional attention. Further investigation revealed that the resident had previously reported a missed dressing change on another occasion, and the MAR showed that the dressing change was falsely signed as completed. The resident also reported missed evening shift dressings over a weekend, which the RNCC acknowledged and stated that the agency nurses involved would be reprimanded. The DON stated that it was not yet established whether the treatments were missed on the reported dates, but the surveyor found the resident's allegations credible based on the documented instances of missed care.
Failure to Ensure Drug Regimens Free from Unnecessary Medications
Penalty
Summary
The facility staff failed to ensure that two residents' drug regimens were free from unnecessary medications. Resident #24 was prescribed sertraline, an antidepressant, and had a documented order to reduce the dosage from 50 mg to 25 mg. However, a subsequent order increased the dosage back to 50 mg without documented justification. Additionally, the facility did not consistently monitor symptoms related to the antidepressant medication, missing key signs of depression such as tearfulness, sluggishness, and decreased involvement in activities. This lack of monitoring was acknowledged by the facility's Director of Nursing (DON) but was not adequately addressed in the behavior monitoring orders provided to the surveyor. Resident #60, who was also prescribed sertraline for Major Depressive Disorder, experienced similar issues. The resident's care plan addressed depression, but the facility's behavior monitoring order did not include comprehensive symptoms of depression. The surveyor noted the absence of consistent symptom monitoring for Resident #60's antidepressant medication, and the DON confirmed that the existing monitoring did not cover all relevant symptoms of depression. This oversight in monitoring critical symptoms of depression was a significant deficiency in the care provided to Resident #60. Both cases highlight the facility's failure to ensure that residents' drug regimens were free from unnecessary medications and that there was consistent and comprehensive monitoring of symptoms related to antidepressant use. The deficiencies were identified through interviews and document reviews, revealing gaps in the facility's medication management and symptom monitoring processes for residents on psychotropic medications.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility staff failed to ensure a medication error rate of less than 5%, resulting in a medication error rate of 5.41%. This deficiency was identified during a survey where it was observed that a Licensed Practical Nurse (LPN) did not administer Aspirin as ordered by the physician and applied an incorrect dosage of a Nicotine Patch to a resident. Specifically, the LPN applied a 21 mg/24-hour Nicotine Patch instead of the prescribed 14 mg/24-hour patch, and failed to administer the prescribed 81 mg Aspirin. The resident involved had multiple diagnoses, including Aftercare following Joint Replacement Surgery, Pneumonia, Generalized Muscle Weakness, Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Hyperlipidemia, and was noted to be lethargic and oriented to person only at the time of admission/re-admission screening. The surveyor's review of the resident's Medication Administration Record (MAR) confirmed the discrepancies between the physician's orders and the medications administered. The LPN acknowledged the errors when questioned by the surveyor, admitting to missing the Aspirin dose and using the incorrect Nicotine Patch despite the correct dosage being available in the medication cart. The facility's policy on Medication Administration was reviewed, which mandates that medications be administered as ordered by the physician and in accordance with professional standards of practice. The survey team discussed these findings with the facility's Administrator and Director of Nursing, but no further information was provided before the exit conference.
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 32 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) |
|---|---|---|---|---|
| Springtree Healthcare & Rehab Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Berkshire Health & Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Our Lady Of The Valley | 2.5 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 3.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Star City Rehabilitation And Nursing.
100% money-back within 48 hours.
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.