Cycle 1
Health 2022-05-26 · Fire 2022-05-26
42 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Harrisonburg, VA
Harrisonburg Hlth & Rehab Cntr
1-star overall rating with 1-star inspections with abuse icon flag with $119,223 in total fines with 42 recent health deficiencies
1225 Reservoir Street, Harrisonburg, VA
(540) 433-2623
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
157
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1975-02-19
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
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
0.29
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.31
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
2.71
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
2.75
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,316
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.42
Baseline 20.88% · Performance 20.77% · Measure score 1.42 · Achievement 1.42 · Improvement 0
Healthcare-associated infections
5.48
Baseline 9.73% · Performance 6.90% · Measure score 5.48 · Achievement 3.14 · Improvement 5.48
Total nurse turnover
0
Performance 62.96% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.50 hours · Performance 2.65 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.15% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 247 · Observed rate 17.41% · Lower 95% interval 10.4% |
| Discharge to community | 52.15% |
50.57%
1.6 pts better
|
No Different than the National Rate · Eligible stays 272 · Observed rate 42.65% · Lower 95% interval 45.08% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.14% |
95.27%
0.1 pts worse
|
Numerator 137 · Denominator 144 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 144 |
| Discharge self-care score | 67.96% |
53.69%
14.3 pts better
|
Numerator 70 · Denominator 103 |
| Discharge mobility score | 59.22% |
50.94%
8.3 pts better
|
Numerator 61 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 7.64% |
2.29%
5.3 pts worse
|
Numerator 11 · Denominator 144 · Adjusted rate 6.19% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 174 · Observed rate 8.05% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 126 |
| Staff flu vaccination coverage | 7.24% |
42%
34.8 pts worse
|
Numerator 22 · Denominator 304 |
| Discharge function score | 64.08% |
56.45%
7.6 pts better
|
Numerator 66 · Denominator 103 |
| Transfer of health information to provider | 93.55% |
95.95%
2.4 pts worse
|
Numerator 29 · Denominator 31 |
| Transfer of health information to patient | 97.01% |
96.28%
0.7 pts better
|
Numerator 65 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 17.91% |
25.2%
7.3 pts worse
|
Numerator 12 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.0 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.4
0.1 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
91.2%
0.7 pts better
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.3% · Q2 91.8% · Q3 94.6% · Q4 95.1% · 4Q avg 91.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.0%
2.2 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| 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 4.8% · Q2 3.4% · Q3 4.7% · Q4 4.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.1% |
15.7%
28.4 pts worse
|
11.4%
32.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.2% · Q2 44.2% · Q3 43.6% · Q4 39.0% · 4Q avg 44.1% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.7%
3.7 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.8% · Q3 0.0% · Q4 0.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.6% |
20.2%
5.4 pts worse
|
19.6%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 27.6% · Q3 25.9% · Q4 24.5% · 4Q avg 25.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
15.0%
2 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.3% · Q3 13.9% · Q4 14.7% · 4Q avg 13.0% · 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 | 7.6% |
17.5%
9.9 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 6.2% · Q3 4.0% · Q4 9.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
15.7%
11.5 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.4% · Q3 1.5% · Q4 3.4% · 4Q avg 4.2% · 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 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.6%
0.1 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.4% · Q3 2.0% · Q4 2.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
22.2%
4.9 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 26.1% · Q3 27.2% · Q4 24.4% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.2%
3.6 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.8% · Q3 9.2% · Q4 7.6% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
74.6%
9.6 pts better
|
81.7%
2.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.0% · Q2 81.6% · Q3 80.6% · Q4 90.8% · 4Q avg 84.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.7%
3.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 16.7% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.2% |
73.6%
9.6 pts better
|
79.7%
3.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.0%
1.3 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 22.8% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-22 · Fire 2021-04-22
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-02 · Fire 2019-05-02
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-04-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-22
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-05-10
E · Potential for more than minimal harm
2019-05-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-06-04
E · Potential for more than minimal harm
2019-05-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-06-19
D · Potential for more than minimal harm
2019-05-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-06-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-09-24
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 2025-12-31
D · Potential for more than minimal harm
2025-09-24
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 2025-12-31
D · Potential for more than minimal harm
2025-09-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-09-24
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-06-05
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 2025-06-30
D · Potential for more than minimal harm
2025-06-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-30
K · Immediate jeopardy
2025-04-11
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 2025-05-21
J · Immediate jeopardy
2025-04-11
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 2025-05-21
G · Actual harm
2025-04-11
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 2025-05-21
G · Actual harm
2025-04-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-05-21
E · Potential for more than minimal harm
2025-04-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-11
E · Potential for more than minimal harm
2025-04-11
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 2025-06-30
E · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
E · Potential for more than minimal harm
2025-04-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-21
E · Potential for more than minimal harm
2025-04-11
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-11
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 2025-05-21
D · Potential for more than minimal harm
2025-04-11
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 2025-05-21
D · Potential for more than minimal harm
2025-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-11
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 2025-05-21
D · Potential for more than minimal harm
2025-04-11
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-11
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-05-21
E · Potential for more than minimal harm
2024-07-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-01-17
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 2024-02-16
D · Potential for more than minimal harm
2024-01-17
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-08-23
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 2023-09-26
D · Potential for more than minimal harm
2023-08-23
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-09-26
E · Potential for more than minimal harm
2022-05-26
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-26
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-26
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 2022-06-28
E · Potential for more than minimal harm
2022-05-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-26
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-26
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 2022-06-28
D · Potential for more than minimal harm
2022-05-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-05-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-05-26
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 2022-06-28
D · Potential for more than minimal harm
2022-05-26
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 2022-06-28
D · Potential for more than minimal harm
2022-05-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-05-26
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 2022-06-28
D · Potential for more than minimal harm
2022-05-26
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-06-28
C · Minimal harm
2022-05-26
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-06-28
E · Potential for more than minimal harm
2021-04-22
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-22
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 2021-06-01
D · Potential for more than minimal harm
2021-04-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-22
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 2021-06-01
D · Potential for more than minimal harm
2021-04-22
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 2021-06-01
D · Potential for more than minimal harm
2021-04-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-22
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 2021-06-01
B · Minimal harm
2021-04-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-06-01
F · Potential for more than minimal harm
2019-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-04
E · Potential for more than minimal harm
2019-05-02
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 2019-06-04
E · Potential for more than minimal harm
2019-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-04
E · Potential for more than minimal harm
2019-05-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-06-04
E · Potential for more than minimal harm
2019-05-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
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 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
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 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
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 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-05-02
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 2019-06-04
D · Potential for more than minimal harm
2019-05-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-06-04
Penalties and ownership
What sits behind the stars
$119,223
2025-04-11
Fine
Fine · fine $119,223
Fine
Ownership
Harrisonburg Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
America West LLC
5% Or Greater Indirect Ownership Interest · Organization
Brooks, Matthew
W-2 Managing Employee · Individual
Charles 1994 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Kss 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ml 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mrv West LLC
5% Or Greater Indirect Ownership Interest · Organization
Rczbm West Manager LLC
Operational/Managerial Control · Organization
Redrock West LLC
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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Sunnyside Presbyterian Retirement Community
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Blue Ridge Rehabilitation And Nursing
Harrisonburg, VA
1-star overall rating with 2-star inspections with $50,436 in total fines with 23 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Vmrc, Complete Living Care
Harrisonburg, VA
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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