Cycle 1
Health 2024-08-22 · Fire 2024-08-22
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
Walter Reed Nursing & Rehabilitation Center
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
Facility snapshot
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
Chain footprint
7 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
0.42
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.20
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
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,078
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.49
Baseline 17.80% · Performance 19.81% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Healthcare-associated infections
3.80
Baseline 6.19% · Performance 6.70% · Measure score 3.80 · Achievement 3.80 · Improvement 0
Total nurse turnover
5.30
Baseline 50.85% · Performance 42.03% · Measure score 5.30 · Achievement 5.30 · Improvement 2.89
Adjusted total nurse staffing
1.04
Baseline 3.33 hours · Performance 3.37 hours · Measure score 1.04 · Achievement 1.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 8.66% · Lower 95% interval 7.49% |
| Discharge to community | 60.03% |
50.57%
9.5 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 55.45% · Lower 95% interval 49.34% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 58 · Denominator 60 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 2 · Denominator 60 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 3 · Denominator 60 · Adjusted rate 6.42% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 5.26% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 157 |
| Staff flu vaccination coverage | 25.77% |
42%
16.2 pts worse
|
Numerator 42 · Denominator 163 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 97.5% |
95.95%
1.5 pts better
|
Numerator 39 · Denominator 40 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 9 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 2.1 · Observed 1.2 · Expected 1.1 · Used in QM five-star |
| 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 · Adjusted 2.7 · Observed 1.8 · Expected 1.1 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 6.6% |
3.6%
3 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.3% · Q3 6.2% · Q4 5.3% · 4Q avg 6.6% · 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 | 9.3% |
5.7%
3.6 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 9.9% · Q3 8.3% · Q4 10.9% · 4Q avg 9.3% |
| 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 · Q1 25.0% · Q2 30.7% · Q3 28.2% · Q4 24.5% · 4Q avg 27.1% |
| 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 · Q1 31.3% · Q2 25.6% · Q3 23.0% · Q4 19.1% · 4Q avg 24.6% · 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 | 9.9% |
17.5%
7.6 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 15.9% · Q3 12.5% · Q4 3.0% · 4Q avg 9.9% · 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 5.3% · Q2 10.3% · Q3 8.7% · Q4 5.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 3.9% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q1 24.9% · Q2 23.0% · Q3 24.5% · Q4 18.1% · 4Q avg 22.6% |
| 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 · Q1 3.4% · Q2 1.7% · Q3 4.5% · Q4 3.9% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 97.8% · Q2 95.9% · Q3 97.8% · Q4 100.0% · 4Q avg 97.8% |
| 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 · Adjusted 8.3% · Observed 8.1% · Expected 10.8% · 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 2.3% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
73.6%
24.4 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| 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 · Adjusted 31.6% · Observed 30.6% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-21 · Fire 2021-05-21
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2018-08-23 · Fire 2018-08-23
12 health 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 citations
F · Potential for more than minimal harm
2021-05-21
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-07-02
F · Potential for more than minimal harm
2021-05-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-07-02
F · Potential for more than minimal harm
2021-05-21
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-05
D · Potential for more than minimal harm
2024-08-22
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 2024-10-05
F · Potential for more than minimal harm
2021-05-21
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 2021-07-02
D · Potential for more than minimal harm
2021-05-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-21
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 2021-07-02
D · Potential for more than minimal harm
2021-05-21
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 2021-07-02
H · Actual harm
2018-08-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-08-23
F · Potential for more than minimal harm
2018-08-23
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 2018-09-26
E · Potential for more than minimal harm
2018-08-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2018-08-23
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 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F803 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2018-08-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-09-26
D · Potential for more than minimal harm
2018-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-26
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Riverside Lifelong Health & Rehabilitation Sanders
Gloucester, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Riverside Lifelong Health And Rehabilitation - M
Mathews, VA
4-star overall rating with 4-star inspections
#3
Riverside Lifelong Health & Rehabilitation Salud
Saluda, VA
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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