Old Southwest Health and Rehabilitation
324 King George Ave Sw · Roanoke, VA · 24016 · 5403458139
130 certified beds For profit - Limited Liability company Chain: Eastern Healthcare Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- 4 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
62% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.36 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.43 | 0.55–0.75 |
| Weekend hours / resident-day | 2.85 | ≈ weekday level |
| Nursing turnover / year | 62% | median 45% |
| Fines (3-yr window) | 2 · $143,823 |
Inspection citations (129 in the current record)
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Potential for harm · E July 16, 2024 · found via 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.
Corrected August 29, 2024 · Resident Rights
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Potential for harm · D July 16, 2024 · found via 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.
Corrected August 29, 2024 · Resident Rights
-
Potential for harm · E July 16, 2024 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected August 29, 2024 · Resident Rights
-
Potential for harm · E July 16, 2024 · found via 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.
Corrected August 29, 2024 · Resident Rights
-
Potential for harm · D July 16, 2024 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected August 29, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 16, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected August 29, 2024 · Resident Assessment and Care Planning
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Potential for harm · E July 16, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected August 29, 2024 · Quality of Life and Care
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Potential for harm · E July 16, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 29, 2024 · Quality of Life and Care
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Potential for harm · D July 16, 2024 · found via 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.
Corrected August 29, 2024 · Quality of Life and Care
-
Potential for harm · E July 16, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 29, 2024 · Quality of Life and Care
-
Potential for harm · F July 16, 2024 · found via 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.
Corrected August 29, 2024 · Nursing and Physician Services
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Potential for harm · D July 16, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected August 29, 2024 · Pharmacy Service
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Potential for harm · D July 16, 2024 · found via complaint
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected August 29, 2024 · Pharmacy Service
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Potential for harm · D July 16, 2024 · found via complaint
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected August 29, 2024 · Pharmacy Service
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Potential for harm · D July 16, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected August 29, 2024 · Pharmacy Service
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Potential for harm · D July 16, 2024 · found via complaint
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected August 29, 2024 · Administration
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Potential for harm · D July 16, 2024 · found via complaint
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected August 29, 2024 · Administration
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Potential for harm · D July 16, 2024 · found via complaint
Keep complete, dated laboratory records in the resident's record.
Corrected August 29, 2024 · Administration
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Potential for harm · D July 16, 2024 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 29, 2024 · Resident Assessment and Care Planning
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Potential for harm · F July 16, 2024 · found via complaint
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected August 29, 2024 · Administration
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Potential for harm · E July 16, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected August 29, 2024 · Infection Control
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Potential for harm · D July 16, 2024 · found via complaint
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected August 29, 2024 · Infection Control
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Potential for harm · D July 16, 2024 · found via 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.
Corrected August 29, 2024 · Infection Control
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Potential for harm · E July 16, 2024 · found via complaint
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected August 29, 2024 · Administration
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Actual harm · G March 29, 2024
Ensure that residents are free from significant medication errors.
Corrected August 29, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 29, 2024 | Fine | $135,633 |
| March 29, 2024 | Payment Denial | 61 days |
| August 16, 2023 | Fine | $8,190 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 495156 · certified since April 25, 1985. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.