Cycle 1
Health 2023-07-20 · Fire 2023-07-20
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gloucester, VA
Riverside Lifelong Health & Rehabilitation Sanders
4-star overall rating with 4-star inspections with 3 recent health deficiencies
7385 Walker Ave, Gloucester, VA
(804) 693-2000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Riverside Health System
Operator or chain grouping
Approved since
2005-01-27
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 3 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
0.93
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.21
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,192
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0054
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.21
Baseline 18.23% · Performance 19.02% · Measure score 5.21 · Achievement 5.21 · Improvement 0
Healthcare-associated infections
6.17
Baseline 5.01% · Performance 5.99% · Measure score 6.17 · Achievement 6.17 · Improvement 0
Total nurse turnover
4.16
Performance 46.67% · Measure score 4.16 · Achievement 4.16 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.91
Baseline 4.61 hours · Performance 4.47 hours · Measure score 4.91 · Achievement 4.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.29% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 350 · Observed rate 7.43% · Lower 95% interval 7.31% |
| Discharge to community | 63.32% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 335 · Observed rate 64.18% · Lower 95% interval 59.06% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.51% |
95.27%
4.2 pts better
|
Numerator 205 · Denominator 206 |
| Falls with major injury | 0.49% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 206 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 87 · Denominator 174 |
| Discharge mobility score | 48.28% |
50.94%
2.7 pts worse
|
Numerator 84 · Denominator 174 |
| Pressure ulcers or injuries, new or worsened | 2.93% |
2.29%
0.6 pts worse
|
Numerator 6 · Denominator 205 · Adjusted rate 3.52% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 211 · Observed rate 3.79% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 4.44% |
8.2%
3.8 pts worse
|
Numerator 6 · Denominator 135 |
| Staff flu vaccination coverage | 98.87% |
42%
56.9 pts better
|
Numerator 175 · Denominator 177 |
| Discharge function score | 50.57% |
56.45%
5.9 pts worse
|
Numerator 88 · Denominator 174 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 162 · Denominator 162 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 26.73% |
25.2%
1.5 pts better
|
Numerator 27 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · 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 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
91.2%
4.7 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 93.8% · Q3 96.6% · Q4 100.0% · 4Q avg 95.9% |
| 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 | 4.9% |
3.6%
1.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.1% · Q3 3.4% · Q4 6.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 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 who lose too much weight | 14.8% |
5.7%
9.1 pts worse
|
5.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 18.2% · Q3 4.5% · Q4 4.3% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
20.2%
11.2 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.6% · Q3 4.5% · Q4 8.3% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
15.0%
3.4 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% · 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 · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
15.7%
5.2 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.5% · Q3 9.5% · Q4 16.7% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 2.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
1.6%
3.3 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 0.0% · Q3 6.9% · Q4 3.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
22.2%
6.6 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 30.1% · Q3 30.3% · Q4 28.4% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.2%
1.8 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 3.6% · Q3 3.6% · Q4 9.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
74.6%
24.6 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 98.9% · Q4 99.4% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
11.7%
5 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 14.6% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 0.8% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
73.6%
25.2 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
22.0%
5.3 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 22.1% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-03 · Fire 2022-03-03
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-07-11 · Fire 2019-07-11
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-03-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-03-21
D · Potential for more than minimal harm
2022-03-03
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-03-21
D · Potential for more than minimal harm
2019-07-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
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 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
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 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-02-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-07-20
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 2023-08-25
D · Potential for more than minimal harm
2023-07-20
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 2023-08-25
D · Potential for more than minimal harm
2023-07-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-25
D · Potential for more than minimal harm
2022-03-03
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-15
G · Actual harm
2019-07-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-08-18
E · Potential for more than minimal harm
2019-07-11
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2019-08-18
E · Potential for more than minimal harm
2019-07-11
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 2019-08-18
E · Potential for more than minimal harm
2019-07-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F578 · Resident Rights Deficiencies
Health
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 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
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 2019-08-18
D · Potential for more than minimal harm
2019-07-11
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 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
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 2019-08-18
D · Potential for more than minimal harm
2019-07-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-07-11
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 2019-09-18
D · Potential for more than minimal harm
2019-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-18
Penalties and ownership
What sits behind the stars
Ownership
Riverside Integrated Services Inc
5% Or Greater Indirect Ownership Interest · Organization
Rector & Visitors Of The University Of Virginia
5% Or Greater Indirect Ownership Interest · Organization
Alewynse, Joyce
Corporate Director · Individual
Austin, Walter
Corporate Officer · Individual
Bates, Jared
Corporate Director · Individual
Dacey, Michael
Corporate Officer · Individual
Downey, William
Corporate Officer · Individual
Haywood, Barbara
Corporate Director · Individual
Heckler, Edward
Corporate Officer · Individual
Houser, Jason
Corporate Officer · Individual
Nelson, Linwood
Operational/Managerial Control · Individual
Riverside Healthcare Association, Inc.
5% Or Greater Direct Ownership Interest · Organization
Smith, Conway
Corporate Director · Individual
Smith, Kirby
Corporate Director · Individual
Tiller, Brooke
Corporate Director · Individual
Verser, Joseph
Corporate Director · Individual
Zeidler, Jeanne
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Walter Reed Nursing & Rehabilitation Center
Gloucester, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Riverside Lifelong Health And Rehabilitation - M
Mathews, VA
4-star overall rating with 4-star inspections
#3
Dockside Health & Rehab Center
Locust Hill, VA
4-star overall rating with 3-star inspections with $14,740 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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