2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gloucester, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
7602 Meredith Drive, Gloucester, VA
(804) 693-6503
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
181
Certified beds
Average residents
145
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Virginia Health Services
Operator or chain grouping
Approved since
1993-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.42
Registered nurse staffing
LPN hours / resident day
1.19
Licensed practical nurse staffing
Aide hours / resident day
2.20
Nurse aide staffing
Weekend hours
3.21
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.4
1.3 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.6%
3 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 9.3% |
5.7%
3.6 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
20.2%
6.9 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
15.0%
9.6 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.9% |
17.5%
7.6 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
22.2%
0.4 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.2%
1.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
74.6%
23.2 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.7%
3.4 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
73.6%
24.4 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.6% |
22.0%
9.6 pts worse
|
23.9%
7.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-07-02
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-07-02
Fire Safety
Provide primary/alternate means for communication.
Corrected 2021-07-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-21
Inspection history
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-05
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 2024-10-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-02
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-02
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-07-02
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 2021-07-02
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-08-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-09-26
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-09-26
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-09-26
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2018-09-26
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-09-26
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-09-26
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 2018-09-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-09-26
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2018-09-26
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-09-26
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-26
Penalties and ownership
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