Inspection Reports for
Friendship Assisted Living, Inc.
320 Hershberger Road, ROANOKE, VA, 24012
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
84 residents
Based on a April 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Deficiencies: 1
Date: Mar 20, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found non-compliance related to the facility's medication management plan, specifically the failure to properly date opened bulk and non-packaged medications, including insulin pens, which were found with blank expiration date stickers.
Deficiencies (1)
Facility failed to implement a portion of its medication management plan regarding methods to prevent the use of outdated, damaged, or contaminated medications, specifically failure to date opened bulk and non-packaged medications such as insulin pens.
Report Facts
Inspection time: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Conducted the renewal inspection |
| Director of Nursing | Discarded unlabeled insulin pens and conducted additional cart audit; responsible for staff meeting and policy review |
Inspection Report
Monitoring
Deficiencies: 1
Date: Apr 30, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 30 and May 1, 2024, to assess compliance with applicable standards and laws at Friendship Assisted Living, Inc.
Findings
The inspection found non-compliance with applicable standards or laws related to medication management, specifically that medications were not kept in pharmacy-issued containers with prescription labels until administration.
Deficiencies (1)
Facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label attached, until administered to the resident.
Report Facts
Inspection duration: 6.25
Inspection duration: 3.75
Inspection Report
Renewal
Deficiencies: 6
Date: Apr 27, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found multiple violations including staff providing care beyond their scope of practice, incomplete individualized service plans, medication management deficiencies such as lack of open date on insulin pens and incorrect medication administration, hazardous materials not stored securely, and physical plant issues like broken window blinds.
Deficiencies (6)
Facility failed to ensure direct care staff only provide services within their scope of practice and training.
Facility failed to ensure all identified needs were addressed on individualized service plans (ISPs).
Facility failed to implement part of its medication management plan regarding prevention of use of outdated, damaged, or contaminated medications.
Facility failed to ensure medication was administered in accordance with physician's instructions.
Facility failed to ensure hazardous materials were stored in a locked area.
Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition.
Report Facts
Inspection duration: 5
Date of physician order for wound care: Jan 15, 2023
Date of physician order for medication change: Mar 7, 2023
Date of uniform assessment instrument: Oct 14, 2022
Date of medication management plan update: Aug 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Johnson | ADON | Updated/corrected individualized service plan (ISP) on 4/27/23 |
| Kim Novak | LPN | Provides healthcare oversight and completes random audits |
| Ashley Davis | LPN | Conducts ISP random audits |
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 8
Date: Apr 19, 2022
Visit Reason
Two inspectors conducted an annual monitoring visit to Friendship Assisted Living, Inc. to review resident and staff files, observe medication pass and activities, and tour the physical plant.
Findings
The facility was found deficient in multiple areas including staff training requirements, fall risk rating updates, completion of uniform assessment instruments, medication administration errors, availability of PRN medications, and unsecured cleaning supplies.
Deficiencies (8)
Facility failed to ensure a direct care staff person had at least 18 hours of training annually.
Facility failed to ensure staff had annual refresher training in methods of dealing with agitated or aggressive residents.
Facility failed to ensure fall risk rating was reviewed and updated annually for residents meeting assisted living care criteria.
Facility failed to complete the uniform assessment instrument (UAI) as required.
Facility failed to ensure staff had annual training in resident rights and responsibilities.
Facility failed to ensure medication was administered in accordance with physician's order (Vitamin D3 order not followed).
Facility failed to have a PRN medication available for a resident as ordered.
Facility failed to have cleaning supplies stored in a locked area.
Report Facts
Residents in care: 84
Staff training hours: 3.75
Medication order date: Apr 12, 2022
Medication order date: Dec 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | Named in multiple findings related to insufficient training and education | |
| Staff 6 | Interviewed regarding fall risk rating for resident 3 | |
| Director of Nursing | Director of Nursing | Responsible for completing routine audits and corrective actions |
| Director of Housekeeping | Director of Housekeeping | Responsible for assuring chemicals are no longer unsecured in the laundry |
Inspection Report
Renewal
Census: 78
Deficiencies: 0
Date: Jun 14, 2021
Visit Reason
A renewal inspection was initiated on 6/14/2021 and concluded on 6/17/2021 to assess compliance with applicable standards and regulations for Friendship Assisted Living, Inc.
Findings
The inspection found no violations with applicable standards or law. No deficiencies were issued during this renewal inspection.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Inspection duration days: 4
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