Old Southwest Health And Rehabilitation
Roanoke, Roanoke City County, Virginia · CCN 495156 · For-profit (LLC) · part of Eastern Healthcare Group (18 facilities, chain average 1.5 stars)
CMS rates Old Southwest Health And Rehabilitation 1 of 5 overall as of August 2026. 130 certified beds, 77 residents a day on average. 129 citations on record from the current inspection cycles, 4 involving actual harm; 1 fine totalling $135,633 and 1 payment denial.
On record
- No health inspection in more than two years, by CMS’s own flag.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 3 / — of 5 |
Staffing
| Total nurse staffing | 3.46966 hours per resident per day |
|---|---|
| Registered nurses | 0.42437 hours per resident per day |
| Weekend total | 3.04546 hours per resident per day |
| Nursing staff turnover | 69.5% (registered nurses 75%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · tag F0865 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · tag F0940 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · tag F0770 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · tag F0773 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · tag F0775 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-07-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · tag F0940 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 complaint survey |
Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 complaint survey |
Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · tag F0770 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · tag F0773 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 complaint survey |
Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · tag F0775 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · tag F0865 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-03-29 | 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 actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-07-16 |
| 2024-03-29 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · tag F0577 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-07-16 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-11-01 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-18 |
| 2023-08-16 complaint survey |
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 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-10-12 |
| 2023-08-16 complaint survey |
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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-12 |
| 2023-08-16 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-27 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2022-07-19 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-08-22 |
| 2021-08-05 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-10-15 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-10-15 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-10-15 |
| 2021-08-05 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-10-15 |
| 2021-08-05 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · tag F0693 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-10-15 |
| 2021-08-05 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Administration Deficiencies · tag F0772 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | 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 No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
| 2021-08-05 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-23 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-03-29 | Payment denial for 61 days from 2024-06-29 | — |
| 2024-03-29 | Fine | $135,633 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Va Snf Operations Holdings 2 LLC Organization | 5% or greater direct ownership interest | 100% | 2024-02-01 |
| Jj United Tr Organization | 5% or greater indirect ownership interest | 50% | 2024-02-01 |
| Shapiro, Akiva Individual | corporate officer | — | 2024-02-01 |
| Shuler, Andrew Individual | w-2 managing employee | — | 2024-02-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Old Southwest Health And Rehabilitation.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Roanoke City County.