Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

FRIENDSHIP HEALTH AND REHAB CENTER - SOUTH

ROANOKE, VA · 120 certified beds · Last Life Safety survey April 25, 2024

CMS Certification Number 495421 · first certified May 2016

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

17
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
11
Inspection & testing records
Of the citations on file

Position within VA

17 citations — more than 74% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was April 2024. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.

This facility17VA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility17
Median facility in VA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
52019-12102022-1022024-04
Citations at each Life Safety survey
Survey dateCitations
December 5, 20195
October 13, 202210
April 25, 20242

Most-cited tags

Most-cited tags at this facility
K-03533K-05111K-03511K-07121K-07611K-02931K-02221K-03451
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32024-04-25
K-0511Have properly installed electrical wiring and gas equipment.12022-10-13
K-0351Install an approved automatic sprinkler system.12024-04-25
K-0712Have simulated fire drills held at unexpected times.12022-10-13
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12022-10-13
K-0293Have properly located and lighted "Exit" signs.12022-10-13
K-0222Add 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.12019-12-05
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12022-10-13

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Egress Deficiencies 3
  • Services Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies3
Services Deficiencies2
Miscellaneous Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 25, 2024 — 2 citations

Citations issued on April 25, 2024
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (June 21, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 21, 2024)

October 13, 2022 — 10 citations

Citations issued on October 13, 2022
TagWhat the surveyor checksStatus
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (December 5, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Waiver has been granted (March 3, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 3, 2023)
K-0363Install corridor and hallway doors that block smoke.Waiver has been granted (March 3, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (December 5, 2022)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (December 5, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 5, 2022)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Waiver has been granted (March 3, 2023)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (December 5, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 5, 2022)

December 5, 2019 — 5 citations

Citations issued on December 5, 2019
TagWhat the surveyor checksStatus
K-0222Add 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.Deficient, Provider has date of correction (January 23, 2020)
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has date of correction (January 23, 2020)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 23, 2020)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (January 23, 2020)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (January 23, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.