Cycle 1
Health 2023-04-13 · Fire 2023-04-13
6 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Clifton Forge, VA
The Woodlands Health And Rehab Center
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1000 Fairview Heights, Clifton Forge, VA
(540) 863-4096
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Commonwealth Care Of Roanoke
Operator or chain grouping
Approved since
2002-05-01
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
0.69
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.40
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,880
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.25
Baseline 17.97% · Performance 20.39% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Healthcare-associated infections
5.95
Baseline 5.50% · Performance 6.06% · Measure score 5.95 · Achievement 5.95 · Improvement 0
Total nurse turnover
5.23
Baseline 51.22% · Performance 42.31% · Measure score 5.23 · Achievement 5.23 · Improvement 2.88
Adjusted total nurse staffing
0.46
Baseline 2.85 hours · Performance 3.13 hours · Measure score 0.46 · Achievement 0 · Improvement 0.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.32% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 10.11% · Lower 95% interval 7.34% |
| Discharge to community | 56.55% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 48.75% · Lower 95% interval 45.92% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 56.6% |
53.69%
2.9 pts better
|
Numerator 30 · Denominator 53 |
| Discharge mobility score | 60.38% |
50.94%
9.4 pts better
|
Numerator 32 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 68 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 3.45% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 8.45% |
8.2%
0.2 pts better
|
Numerator 6 · Denominator 71 |
| Staff flu vaccination coverage | 37.78% |
42%
4.2 pts worse
|
Numerator 34 · Denominator 90 |
| Discharge function score | 66.04% |
56.45%
9.6 pts better
|
Numerator 35 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.5% |
25.2%
2.7 pts worse
|
Numerator 9 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.2%
8.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 2.0% · Q4 2.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
15.7%
13.2 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.8% · Q4 2.4% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.7%
3.5 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 6.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
20.2%
4.9 pts worse
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 24.4% · Q3 26.0% · Q4 26.0% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
15.0%
9.5 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 21.6% · Q3 25.6% · Q4 26.2% · 4Q avg 24.5% · 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 | 12.8% |
17.5%
4.7 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 16.7% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
15.7%
8.2 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.6% · Q3 9.3% · Q4 6.7% · 4Q avg 7.5% · 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 | 0.5% |
1.6%
1.1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
22.2%
1.3 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 15.5% · Q3 20.2% · Q4 31.4% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.2%
2.2 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.4% · Q3 5.7% · Q4 1.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
74.6%
17.3 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.9% · Q2 91.2% · Q3 100.0% · Q4 93.3% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
11.7%
2.2 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 14.9% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 3.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
73.6%
23.9 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
22.0%
2.9 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 23.4% · Expected 29.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-28 · Fire 2021-07-28
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-04-03 · Fire 2019-04-03
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-04-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-04-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-04-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-04-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-13
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-16
D · Potential for more than minimal harm
2021-07-28
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-08-25
D · Potential for more than minimal harm
2021-07-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-08-25
F · Potential for more than minimal harm
2019-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-04-30
D · Potential for more than minimal harm
2019-04-03
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-04-30
D · Potential for more than minimal harm
2019-04-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-04-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-04-13
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
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 2023-05-12
E · Potential for more than minimal harm
2021-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-31
C · Minimal harm
2021-07-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-08-31
B · Minimal harm
2021-07-28
F584 · Resident Rights Deficiencies
Health
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 2021-08-31
D · Potential for more than minimal harm
2019-04-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-04-03
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 2019-04-19
Penalties and ownership
What sits behind the stars
Ownership
Dj Petrine LLC
5% Or Greater Direct Ownership Interest · Organization
Goodall, Lury
5% Or Greater Direct Ownership Interest · Individual
Sheffer, Brady
5% Or Greater Direct 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
Baldwin, Angela
W-2 Managing Employee · Individual
Commonwealth Care Of Roanoke Inc
Operational/Managerial Control · Organization
Dj Petrine LLC
Operational/Managerial Control · Organization
Goodall, Lury
Corporate Director · Individual
Petrine, Deborah
Corporate Director · Individual
Stallard, Patricia
Corporate Director · Individual
Tucker, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Alleghany Health And Rehab
Clifton Forge, VA
1-star overall rating with 1-star inspections with $108,698 in total fines with 17 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Brian Center Of Alleghany
Low Moor, VA
5-star overall rating with 4-star inspections with 10 recent health deficiencies
#3
The Springs Nursing & Rehab Center
Hot Springs, VA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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