West Point, VA

Three Rivers Health & Rehab Center

4-star overall rating with 3-star inspections with $8,492 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

2960 Chelsea Road, West Point, VA

(757) 843-4323

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1995-09-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.53

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.94

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

1.94

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

3.41

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.47

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

2.86

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.48

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,754

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

Performance score

42.82

Composite VBP score used to determine payment impact.

Payment multiplier

0.9958

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.82

Baseline 23.53% · Performance 18.77% · Measure score 6.82 · Achievement 5.75 · Improvement 6.82

Healthcare-associated infections

7.42

Baseline 8.27% · Performance 5.68% · Measure score 7.42 · Achievement 7.22 · Improvement 7.42

Total nurse turnover

2.86

Baseline 56.36% · Performance 52.00% · Measure score 2.86 · Achievement 2.86 · Improvement 0.88

Adjusted total nurse staffing

0.02

Baseline 2.87 hours · Performance 3.02 hours · Measure score 0.02 · Achievement 0 · Improvement 0.02

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.02%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 95 · Observed rate 11.58% · Lower 95% interval 7.25%
Discharge to community	60.37%	50.57% 9.8 pts better	No Different than the National Rate · Eligible stays 77 · Observed rate 58.44% · Lower 95% interval 50.45%
Medicare spending per beneficiary	0.93	1.02 0.1 pts better
Drug regimen review with follow-up	98.84%	95.27% 3.6 pts better	Numerator 85 · Denominator 86
Falls with major injury	1.16%	0.77% 0.4 pts worse	Numerator 1 · Denominator 86
Discharge self-care score	42.55%	53.69% 11.1 pts worse	Numerator 20 · Denominator 47
Discharge mobility score	57.45%	50.94% 6.5 pts better	Numerator 27 · Denominator 47
Pressure ulcers or injuries, new or worsened	1.16%	2.29% 1.1 pts better	Numerator 1 · Denominator 86 · Adjusted rate 0.82%
Healthcare-associated infections requiring hospitalization	5.68%	7.12% 1.4 pts better	No Different than the National Rate · Eligible stays 66 · Observed rate 1.52% · Lower 95% interval 3.07%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 115
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	72.34%	56.45% 15.9 pts better	Numerator 34 · Denominator 47
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 25 · Denominator 25
Transfer of health information to patient	90.7%	96.28% 5.6 pts worse	Numerator 39 · Denominator 43
Resident COVID-19 vaccinations up to date	4.08%	25.2% 21.1 pts worse	Numerator 2 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	1.5 0.4 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.4 1 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	91.2% 8.2 pts better	93.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.5% · Q4 100.0% · 4Q avg 99.4%
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	4.3%	3.6% 0.7 pts worse	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.4% · Q3 5.0% · Q4 4.9% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.4%	15.7% 8.3 pts better	11.4% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.9% · Q3 8.1% · Q4 10.8% · 4Q avg 7.4%
Percentage of long-stay residents who lose too much weight	2.6%	5.7% 3.1 pts better	5.4% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.5% · Q3 5.3% · Q4 0.0% · 4Q avg 2.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.2%	20.2% 8 pts worse	19.6% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 24.4% · Q3 31.6% · Q4 30.0% · 4Q avg 28.2%
Percentage of long-stay residents who received an antipsychotic medication	16.3%	15.0% 1.3 pts worse	16.7% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 17.2% · Q3 16.1% · Q4 15.6% · 4Q avg 16.3% · 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	24.1%	17.5% 6.6 pts worse	16.3% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.7%	15.7% 4 pts better	14.9% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 18.4% · Q3 5.9% · Q4 8.6% · 4Q avg 11.7% · 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	0.6%	1.6% 1 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.4%	22.2% 2.8 pts better	19.8% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 14.8% · Q3 17.0% · Q4 15.2% · 4Q avg 19.4%
Percentage of long-stay residents with pressure ulcers	0.5%	5.2% 4.7 pts better	5.1% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.0%	74.6% 19.4 pts better	81.7% 12.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 96.0% · Q3 93.5% · Q4 94.4% · 4Q avg 94.0%
Percentage of short-stay residents who had an outpatient emergency department visit	13.5%	11.7% 1.8 pts worse	12.0% 1.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 12.0% · Expected 9.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.7%	73.6% 21.1 pts better	79.7% 15 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.9%	22.0% 1.1 pts better	23.9% 3 pts better	Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 18.7% · Expected 21.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-01 · Fire 2024-03-01

8 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2021-07-29 · Fire 2021-07-29

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2018-11-01 · Fire 2018-11-01

13 health deficiencies

Top issue: Resident Rights (5 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-03-01

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-03-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-03-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-03-15

D · Potential for more than minimal harm 2018-11-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-02-20

D · Potential for more than minimal harm 2018-11-01

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2019-02-20

D · Potential for more than minimal harm 2018-11-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-02-20

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-03-01

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-04-01

E · Potential for more than minimal harm 2024-03-01

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-03-01

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-03-01

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 2024-04-01

D · Potential for more than minimal harm 2024-03-01

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-03-01

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 2024-04-01

D · Potential for more than minimal harm 2024-03-01

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-03-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-01

G · Actual harm 2023-09-13

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-10-24

D · Potential for more than minimal harm 2023-09-13

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-10-24

D · Potential for more than minimal harm 2023-09-13

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-09-13

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 2023-10-24

D · Potential for more than minimal harm 2023-09-13

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-10-24

D · Potential for more than minimal harm 2023-09-13

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 2023-10-24

G · Actual harm 2021-07-29

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-09-01

E · Potential for more than minimal harm 2021-07-29

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2021-09-01

E · Potential for more than minimal harm 2021-07-29

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 2021-09-01