OLD SOUTHWEST HEALTH AND REHABILITATION
Open-data reference.
OLD SOUTHWEST HEALTH AND REHABILITATION is a for profit - limited liability company facility in ROANOKE, VA with 130 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $144K.
324 KING GEORGE AVE SW, ROANOKE, VA 24016
Phone: 5403458139
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 495156
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 130
- Residents
- 95
- In Hospital
- No
- County
- Roanoke City
- Last Inspection
- Mar 29, 2024
Staffing Data
- RN Hours
- 0.34 (nat'l avg: 0.68)
- LPN Hours
- 1.12
- CNA Hours
- 2.03
- Total Nursing Hours
- 3.48 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 69.9%
- RN Turnover
- 94.4%
What the CMS Record Reveals About OLD SOUTHWEST HEALTH AND REHABILITATION
OLD SOUTHWEST HEALTH AND REHABILITATION operates 130 certified beds in ROANOKE, VA with approximately 95 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $144K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.48 total nursing hours per resident day (national average 3.89), with RN coverage at 0.34 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, OLD SOUTHWEST HEALTH AND REHABILITATION falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 69.9%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
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.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2024
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2024
Keep complete, dated laboratory records in the resident's record.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 29, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2024
Keep complete, dated laboratory records in the resident's record.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2024
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 16, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Jul 16, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 16, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Jul 16, 2024
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 16, 2024
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Category: Resident Rights Deficiencies
Corrected: Jul 16, 2024
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Category: Administration Deficiencies
Corrected: Jul 16, 2024
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
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.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Jul 16, 2024
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2024
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: Aug 29, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 29, 2024
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 14.4% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.4% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 53.1% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 10.5% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.6% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 18.0% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 20.8% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 20.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 5.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 8.1% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 30.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 20.2% | Yes |
Penalty History 2 penalties totaling $144K
| Date | Type | Amount |
|---|---|---|
| Mar 29, 2024 | Fine | $136K |
| Mar 29, 2024 | Payment Denial | - |
| Aug 16, 2023 | Fine | $8K |
| Mar 13, 2023 | Fine | $2K |
| Mar 6, 2023 | Fine | $2K |
| Feb 28, 2023 | Fine | $2K |
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Understanding Nursing Home Data
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Frequently Asked Questions
What is the overall CMS rating for OLD SOUTHWEST HEALTH AND REHABILITATION?
What are the staffing levels at OLD SOUTHWEST HEALTH AND REHABILITATION?
How many beds does OLD SOUTHWEST HEALTH AND REHABILITATION have?
Does OLD SOUTHWEST HEALTH AND REHABILITATION have any deficiencies on record?
Has OLD SOUTHWEST HEALTH AND REHABILITATION received any fines or penalties?
Who owns OLD SOUTHWEST HEALTH AND REHABILITATION?
When was OLD SOUTHWEST HEALTH AND REHABILITATION last inspected?
What quality measures are tracked for OLD SOUTHWEST HEALTH AND REHABILITATION?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.