nursing home in Roanoke, VA
Old Southwest Health and Rehabilitation
324 King George Ave SW, Roanoke, VA 24016 · (540) 345-8139
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★1
- Staffing★★★★★2
- Quality measures★★★★★3
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Old Southwest Health and Rehabilitation at a glance
Old Southwest Health and Rehabilitation is a 130-bed for-profit nursing home in Roanoke, Virginia (Roanoke City County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the Virginia average of 3.
Residents receive about 3.5 hours of nursing care per day (0.4 of them from registered nurses), worse than the state average of 3.8 hours.
Its most recent standard health inspection (March 29, 2024) found 46 health citations. The Virginia average is 14.4.
Federal regulators fined it 1 time in the past three years, totaling $135,633.
Nursing staff turnover is 69.5% per year (state average 48.1%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 130
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Eastern Healthcare Group
- Medicare-certified since
- April 25, 1985
- Resident/family council
- Resident
- County
- Roanoke City County
- CMS Certification Number
- 495156
Ratings
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 3 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 1 / 5 | 2.7 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 2 / 5 | 2.4 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 3 / 5 | 3.9 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 3 / 5 | 4 / 5 | 3.8 / 5 | Worse |
Staffing
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.47 hrs | 3.76 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.42 hrs | 0.69 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 1.73 hrs | 2.07 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 3.05 hrs | 3.29 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 69.5% | 48.1% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 75% | 48.2% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 46 | 14 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 5 | 4 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 419 | 122.3 | 80.6 | Worse |
Penalties
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $135,633 | $23,688 | $30,972 | Worse |
| All federal penalties in the past 3 years (lower is better) | 2 | 1 | 1 | Worse |
Size
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 130 | 113 | 107 | |
| Average residents per day | 77 | 99 | 86 | |
| Occupancy | 58.8% | 87.9% | 80.9% |
Long-stay residents
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 3.6% | 3.6% | 3.2% | Worse |
| Long-stay residents with pressure ulcers (lower is better) | 7.9% | 4.7% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 21.3% | 14.2% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 1.5% | 1.6% | 1.6% | Average |
| Long-stay residents with a catheter left in the bladder (lower is better) | 1.1% | 0.4% | 0.8% | Worse |
| Long-stay residents needing more help with daily activities (lower is better) | 13.1% | 14.9% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 14.2% | 15.6% | 14.1% | Average |
| Long-stay residents who lose too much weight (lower is better) | 6.6% | 5.4% | 5.2% | Worse |
| Long-stay residents with depressive symptoms (lower is better) | 12.8% | 18.7% | 12.8% | Average |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 24.8% | 20.6% | 19.5% | Worse |
| Long-stay residents with new or worse incontinence (lower is better) | 29.5% | 21.8% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 20% | 94% | 95.5% | Worse |
| Long-stay residents given a pneumonia vaccine (higher is better) | 49.4% | 90.9% | 93.6% | Worse |
Short-stay residents
| Measure | This facility | Virginia avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 0% | 1.3% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 5.7% | 73.6% | 79.8% | Worse |
| Short-stay residents given a pneumonia vaccine (higher is better) | 5.9% | 73.7% | 82% | Worse |
Inspection citations
State inspectors cited this home for 126 health deficiencies and 27 fire safety deficiencies in the inspection records CMS currently publishes. 3 citations involved actual harm.
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 16, 2024 Complaint | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Tag F0726 | F Potential harm, widespread | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Tag F0865 | F Potential harm, widespread | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Tag F0623 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | 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. Resident Rights Deficiencies · Tag F0625 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | 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. Resident Rights Deficiencies · Tag F0578 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Tag F0940 | E Potential harm, pattern | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Tag F0773 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · Tag F0775 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Tag F0756 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | 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. Infection Control Deficiencies · Tag F0887 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Tag F0688 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected August 29, 2024 |
| July 16, 2024 Complaint | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Tag F0770 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Fire safety | Meet other general requirements. Smoke Deficiencies · Tag K0932 | F Potential harm, widespread | Corrected July 1, 2024 |
| March 29, 2024 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | E Potential harm, pattern | Corrected July 1, 2024 |
| March 29, 2024 Fire safety | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Tag E0037 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | E Potential harm, pattern | Corrected July 1, 2024 |
| March 29, 2024 Fire safety | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Tag K0347 | D Potential harm, isolated | Corrected July 1, 2024 |
| March 29, 2024 Fire safety | Have properly installed hallway dispensers for alcohol-based hand rub. Smoke Deficiencies · Tag K0325 | D Potential harm, isolated | Corrected July 1, 2024 |
| March 29, 2024 Fire safety | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Tag K0341 | D Potential harm, isolated | Corrected July 1, 2024 |
| March 29, 2024 Fire safety | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Tag K0346 | D Potential harm, isolated | Corrected July 1, 2024 |
| March 29, 2024 Standard | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | G Actual harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Tag F0867 | G Actual harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Tag F0726 | F Potential harm, widespread | Corrected August 29, 2024 |
| March 29, 2024 Complaint | 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. Resident Rights Deficiencies · Tag F0578 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Tag F0623 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | 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. Resident Rights Deficiencies · Tag F0625 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Tag F0949 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Tag F0947 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Tag F0944 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Tag F0942 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Tag F0941 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Tag F0940 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | 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. Infection Control Deficiencies · Tag F0887 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Tag F0756 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Tag F0730 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected August 29, 2024 |
| March 29, 2024 Standard | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | E Potential harm, pattern | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Tag F0561 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Tag F0688 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Tag F0636 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Tag F0773 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Standard | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Tag F0679 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Complaint | Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · Tag F0775 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Tag F0865 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Complaint | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Complaint | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Complaint | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 29, 2024 Complaint | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Tag F0770 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected August 29, 2024 |
| March 29, 2024 Standard | Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Resident Rights Deficiencies · Tag F0575 | C No harm, widespread | Corrected July 16, 2024 |
| March 29, 2024 Standard | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Tag F0577 | C No harm, widespread | Corrected July 16, 2024 |
| November 1, 2023 Complaint | 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. Pharmacy Service Deficiencies · Tag F0761 | F Potential harm, widespread | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Tag F0584 | E Potential harm, pattern | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | E Potential harm, pattern | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Tag F0655 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Provide appropriate foot care. Quality of Life and Care Deficiencies · Tag F0687 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected January 18, 2024 |
| November 1, 2023 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected January 18, 2024 |
| July 19, 2022 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | F Potential harm, widespread | Corrected September 12, 2022 |
| July 19, 2022 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | F Potential harm, widespread | Corrected February 14, 2023 |
| July 19, 2022 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | F Potential harm, widespread | Corrected September 12, 2022 |
| July 19, 2022 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected September 12, 2022 |
| July 19, 2022 Fire safety | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Tag K0222 | E Potential harm, pattern | Corrected September 12, 2022 |
| July 19, 2022 Fire safety | Have properly located and lighted "Exit" signs. Egress Deficiencies · Tag K0293 | E Potential harm, pattern | Corrected September 12, 2022 |
| July 19, 2022 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | E Potential harm, pattern | Corrected September 12, 2022 |
| July 19, 2022 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | E Potential harm, pattern | Corrected February 14, 2023 |
| July 19, 2022 Fire safety | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Tag K0711 | D Potential harm, isolated | Corrected February 14, 2023 |
| July 19, 2022 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | D Potential harm, isolated | Corrected February 14, 2023 |
| July 19, 2022 Standard | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Tag F0645 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | 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. Resident Rights Deficiencies · Tag F0625 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | 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. Resident Rights Deficiencies · Tag F0578 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Tag F0756 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected August 22, 2022 |
| July 19, 2022 Standard | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected August 22, 2022 |
| August 5, 2021 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | F Potential harm, widespread | Corrected February 1, 2022 |
| August 5, 2021 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected November 10, 2021 |
| August 5, 2021 Fire safety | Have properly located and lighted "Exit" signs. Egress Deficiencies · Tag K0293 | E Potential harm, pattern | Corrected November 10, 2021 |
| August 5, 2021 Fire safety | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0914 | E Potential harm, pattern | Corrected September 21, 2021 |
| August 5, 2021 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | E Potential harm, pattern | Corrected February 1, 2022 |
| August 5, 2021 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | E Potential harm, pattern | Corrected September 21, 2021 |
| August 5, 2021 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | D Potential harm, isolated | Corrected September 21, 2021 |
| August 5, 2021 Fire safety | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Tag K0222 | D Potential harm, isolated | Corrected February 1, 2022 |
| August 5, 2021 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | G Actual harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | E Potential harm, pattern | Corrected September 23, 2021 |
| August 5, 2021 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | E Potential harm, pattern | Corrected October 15, 2021 |
| August 5, 2021 Standard | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected October 15, 2021 |
| August 5, 2021 Standard | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | E Potential harm, pattern | Corrected October 15, 2021 |
| August 5, 2021 Standard | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Tag F0919 | E Potential harm, pattern | Corrected October 15, 2021 |
| August 5, 2021 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Administration Deficiencies · Tag F0772 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0691 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Tag F0690 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Tag F0645 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | 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. Resident Rights Deficiencies · Tag F0622 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 | D Potential harm, isolated | Corrected September 23, 2021 |
| August 5, 2021 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected October 15, 2021 |
Showing the 150 most recent of 153 citations.
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 2 federal penalties in the past three years, including $135,633 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| March 29, 2024 | Payment Denial | 61 days from June 29, 2024 |
| March 29, 2024 | Fine | $135,633 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| VA SNF OPERATIONS HOLDINGS 2 LLC Organization | 5% or greater direct ownership interest | 100% | 02/01/2024 |
| JJ UNITED TR Organization | 5% or greater indirect ownership interest | 50% | 02/01/2024 |
| SHAPIRO, AKIVA Individual | corporate officer | NOT APPLICABLE | 02/01/2024 |
| SHULER, ANDREW Individual | w-2 managing employee | NOT APPLICABLE | 02/01/2024 |
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★★★★★3AveragePheasant Ridge Nursing and Rehabilitation
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- Abuse citation
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★★★★★2Below averageBerkshire Health & Rehabilitation Center
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Frequently asked questions
What is Old Southwest Health and Rehabilitation's rating?
Old Southwest Health and Rehabilitation has 1 out of 5 stars on the CMS overall star rating. The average for Virginia nursing homes is 3 stars.
How many inspection citations did Old Southwest Health and Rehabilitation receive?
Its most recent standard health inspection found 46 citations, compared with a Virginia average of 14.4. Every citation is listed on this page with its severity.
Does Old Southwest Health and Rehabilitation accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Old Southwest Health and Rehabilitation?
It is for profit - limited liability company and part of Eastern Healthcare Group. The ownership section on this page lists the owners and managers reported to CMS.
Where is Old Southwest Health and Rehabilitation and how do I contact it?
Old Southwest Health and Rehabilitation is at 324 King George Ave SW, Roanoke, VA 24016. Phone: (540) 345-8139.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.