Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
OLD SOUTHWEST HEALTH AND REHABILITATION
ROANOKE, VA · 130 certified beds · Last Life Safety survey March 29, 2024
CMS Certification Number 495156 · first certified April 1985
Ownership
Operated by EASTERN HEALTHCARE GROUP · For profit - Limited Liability company
- Ownership changed February 1, 2024 (change of ownership)from 324 KING GEORGE OPCO LLC
Position within VA
27 citations — more than 94% 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
The latest survey found 9 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was March 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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4 inspection-and-testing tags have 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.
Emergency preparedness
2 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
12 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 27 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 5, 2021 | 8 |
| July 19, 2022 | 10 |
| March 29, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 3 | 2024-03-29 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2022-07-19 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2022-07-19 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2022-07-19 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2022-07-19 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2022-07-19 |
| K-0222 | 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. | 2 | 2022-07-19 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2022-07-19 |
What the citations cover
- Smoke Deficiencies 11
- Miscellaneous Deficiencies 6
- Egress Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Miscellaneous Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 29, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 16, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 16, 2024) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (July 1, 2024) |
| K-0932 | Meet other general requirements. | Waiver has been granted (July 1, 2024) |
July 19, 2022 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (September 12, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Waiver has been granted (February 14, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (February 14, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (February 14, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 14, 2023) |
August 5, 2021 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Waiver has been granted (February 1, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 10, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 10, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 21, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Waiver has been granted (February 1, 2022) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 21, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (February 1, 2022) |
| K-0914 | Ensure 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 (September 21, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.