Cycle 1
Health 2025-03-06 · Fire 2025-03-06
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pennington Gap, VA
Lee Health And Rehab Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies
208 Health Care Drive, Pennington Gap, VA
(276) 546-4566
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Commonwealth Care Of Roanoke
Operator or chain grouping
Approved since
2001-08-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.89
Composite VBP score used to determine payment impact.
Payment multiplier
1.0003
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.09
Baseline 21.58% · Performance 20.46% · Measure score 2.09 · Achievement 2.09 · Improvement 1.96
Healthcare-associated infections
6.96
Baseline 12.27% · Performance 6.85% · Measure score 6.96 · Achievement 3.31 · Improvement 6.96
Total nurse turnover
8.78
Baseline 44.68% · Performance 27.78% · Measure score 8.78 · Achievement 8.78 · Improvement 8.02
Adjusted total nurse staffing
0.92
Baseline 2.79 hours · Performance 3.22 hours · Measure score 0.92 · Achievement 0 · Improvement 0.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.15% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 14.29% · Lower 95% interval 8.37% |
| Discharge to community | 54.56% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 47.93% · Lower 95% interval 45.76% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 47.06% |
53.69%
6.6 pts worse
|
Numerator 24 · Denominator 51 |
| Discharge mobility score | 56.86% |
50.94%
5.9 pts better
|
Numerator 29 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 69 · Adjusted rate 3.11% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 3.37% |
| Staff COVID-19 vaccination coverage | 8.84% |
8.2%
0.6 pts better
|
Numerator 13 · Denominator 147 |
| Staff flu vaccination coverage | 32.68% |
42%
9.3 pts worse
|
Numerator 50 · Denominator 153 |
| Discharge function score | 60.78% |
56.45%
4.3 pts better
|
Numerator 31 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 6 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.4
0.3 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.0%
4 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.6%
1.6 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.5% · Q3 4.8% · Q4 6.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
15.7%
11.4 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.6% · Q3 10.8% · Q4 4.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.7%
1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.5% · Q3 6.2% · Q4 3.6% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
20.2%
5.5 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 26.1% · Q3 24.7% · Q4 25.3% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.8% |
15.0%
6.8 pts worse
|
16.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 21.1% · Q3 19.1% · Q4 26.5% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.5% |
17.5%
3 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 25.5% · Q3 12.3% · Q4 9.8% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
15.7%
2.5 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 20.5% · Q3 22.5% · Q4 12.3% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.6%
0.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
22.2%
0.5 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 22.3% · Q3 19.4% · Q4 15.4% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.2%
2.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.5% · Q3 1.4% · Q4 2.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
74.6%
23.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.5% · Q3 99.4% · Q4 96.1% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
11.7%
1.3 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.3% · Q4 2.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
73.6%
21.9 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
22.0%
2.5 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 19.0% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-02 · Fire 2022-06-02
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-01-09 · Fire 2020-01-09
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-06-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-08-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-25
D · Potential for more than minimal harm
2023-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-05
D · Potential for more than minimal harm
2022-06-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-07-26
D · Potential for more than minimal harm
2020-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-02-07
Penalties and ownership
What sits behind the stars
Ownership
Dj Petrine LLC
5% Or Greater Direct Ownership Interest · Organization
Bdsheffer LLC
5% Or Greater Direct Ownership Interest · Organization
Goodall, Lury
5% Or Greater Direct Ownership Interest · Individual
Sheffer, Brady
5% Or Greater Indirect Ownership Interest · Individual
Stallard, Patricia
5% Or Greater Direct Ownership Interest · Individual
Petrine, Deborah
5% Or Greater Indirect Ownership Interest · Individual
Petrine, James
5% Or Greater Indirect Ownership Interest · Individual
Alesantrino, Joe
Corporate Officer · Individual
Commonwealth Care Of Roanoke Inc
Operational/Managerial Control · Organization
Petrine, Deborah
Corporate Officer · Individual
Rehnborg, Charles
W-2 Managing Employee · Individual
Tucker, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Ridgecrest Manor Nursing & Rehabilitation
Duffield, VA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Tri Cities Rehabilitation and Healthcare Center
Cumberland, KY
3-star overall rating with 2-star inspections with $5,346 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Harlan Health and Rehabilitation Center
Harlan, KY
1-star overall rating with 2-star inspections with $10,868 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out