Danville, VA

Riverside Health & Rehab Cntr

3-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

2344 Riverside Drive, Danville, VA

(434) 791-3800

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

180

Certified beds

Average residents

168

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lifeworks Rehab

Operator or chain grouping

Approved since

1995-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

59 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.41

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.98

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

1.77

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

3.16

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.39

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

2.58

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

2.75

CMS adjusted total nurse staffing hours

Case-mix index

1.57

Higher values indicate more complex resident acuity

RN turnover

21%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,670

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.35

Composite VBP score used to determine payment impact.

Payment multiplier

0.9890

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.81

Baseline 20.98% · Performance 17.81% · Measure score 7.81 · Achievement 7.81 · Improvement 7.52

Healthcare-associated infections

4.55

Baseline 7.52% · Performance 6.48% · Measure score 4.55 · Achievement 4.55 · Improvement 3.63

Total nurse turnover

1.78

Performance 56.39% · Measure score 1.78 · Achievement 1.78 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

Baseline 2.99 hours · Performance 2.70 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.65%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 126 · Observed rate 14.29% · Lower 95% interval 8.51%
Discharge to community	53.63%	50.57% 3.1 pts better	No Different than the National Rate · Eligible stays 144 · Observed rate 45.14% · Lower 95% interval 41.91%
Medicare spending per beneficiary	1.45	1.02 0.4 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 85 · Denominator 85
Falls with major injury	1.18%	0.77% 0.4 pts worse	Numerator 1 · Denominator 85
Discharge self-care score	48.21%	53.69% 5.5 pts worse	Numerator 27 · Denominator 56
Discharge mobility score	37.5%	50.94% 13.4 pts worse	Numerator 21 · Denominator 56
Pressure ulcers or injuries, new or worsened	3.53%	2.29% 1.2 pts worse	Numerator 3 · Denominator 85 · Adjusted rate 2.85%
Healthcare-associated infections requiring hospitalization	6.48%	7.12% 0.6 pts better	No Different than the National Rate · Eligible stays 87 · Observed rate 5.75% · Lower 95% interval 3.89%
Staff COVID-19 vaccination coverage	5.35%	8.2% 2.8 pts worse	Numerator 10 · Denominator 187
Staff flu vaccination coverage	10%	42% 32 pts worse	Numerator 22 · Denominator 220
Discharge function score	42.86%	56.45% 13.6 pts worse	Numerator 24 · Denominator 56
Transfer of health information to provider	75%	95.95% 21 pts worse	Numerator 42 · Denominator 56
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	21.67%	25.2% 3.5 pts worse	Numerator 13 · Denominator 60

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.5 0.2 pts worse	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	1.4 0.4 pts worse	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	91.2% 7.6 pts better	93.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 98.7% · Q4 97.8% · 4Q avg 98.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.1%	94.0% 4.1 pts better	95.5% 2.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1%
Percentage of long-stay residents experiencing one or more falls with major injury	2.9%	3.6% 0.7 pts better	3.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.6% · Q3 3.9% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	62.0%	15.7% 46.3 pts worse	11.4% 50.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 71.2% · Q2 66.7% · Q3 51.8% · Q4 58.5% · 4Q avg 62.0%
Percentage of long-stay residents who lose too much weight	11.6%	5.7% 5.9 pts worse	5.4% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.0% · Q3 14.0% · Q4 9.7% · 4Q avg 11.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.6%	20.2% 8.4 pts worse	19.6% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 26.8% · Q3 31.4% · Q4 31.0% · 4Q avg 28.6%
Percentage of long-stay residents who received an antipsychotic medication	16.0%	15.0% 1 pts worse	16.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 16.3% · Q3 15.5% · Q4 16.8% · 4Q avg 16.0% · 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	14.9%	17.5% 2.6 pts better	16.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 17.6% · Q3 15.7% · Q4 14.2% · 4Q avg 14.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.7%	15.7% 3 pts better	14.9% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.0% · Q3 14.8% · Q4 12.5% · 4Q avg 12.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.5% 0.2 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.4% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.0%	1.6% 2.4 pts worse	1.7% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.8% · Q3 5.3% · Q4 3.0% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.1%	22.2% 5.1 pts better	19.8% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 17.0% · Q3 16.8% · Q4 15.0% · 4Q avg 17.1%
Percentage of long-stay residents with pressure ulcers	6.5%	5.2% 1.3 pts worse	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.0% · Q3 5.6% · Q4 6.4% · 4Q avg 6.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.6%	74.6% 3 pts better	81.7% 4.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 78.8% · Q3 71.7% · Q4 70.1% · 4Q avg 77.6%
Percentage of short-stay residents who had an outpatient emergency department visit	16.1%	11.7% 4.4 pts worse	12.0% 4.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 16.2% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.2% About the same	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.3% · Q3 0.0% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	80.4%	73.6% 6.8 pts better	79.7% 0.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.4%	22.0% 3.4 pts worse	23.9% 1.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 26.1% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-09-07 · Fire 2023-09-07

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2021-03-11 · Fire 2021-03-11

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2019-02-21 · Fire 2019-02-21

12 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2023-09-07

K932 · Smoke Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-02-09

E · Potential for more than minimal harm 2021-03-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-05-19

E · Potential for more than minimal harm 2021-03-11

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-05-19

D · Potential for more than minimal harm 2021-03-11

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2021-05-19

D · Potential for more than minimal harm 2021-03-11

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2021-05-19

D · Potential for more than minimal harm 2021-03-11

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2021-05-19

F · Potential for more than minimal harm 2019-02-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-04-30

F · Potential for more than minimal harm 2019-02-21

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2019-04-30

F · Potential for more than minimal harm 2019-02-21

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-04-30

Inspection history

Recent health citations

D · Potential for more than minimal harm 2023-09-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-09-07

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 2023-11-22

D · Potential for more than minimal harm 2023-09-07

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-09-07

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 2023-11-22

D · Potential for more than minimal harm 2023-09-07

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-11-22

E · Potential for more than minimal harm 2021-03-11

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2021-04-20

D · Potential for more than minimal harm 2021-03-11

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 2021-04-20

D · Potential for more than minimal harm 2021-03-11

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2021-04-20

D · Potential for more than minimal harm 2021-03-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-04-20

D · Potential for more than minimal harm 2021-03-11

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 2021-04-20

F · Potential for more than minimal harm 2019-02-21

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 2019-04-02