Cycle 1
Health 2023-02-09 · Fire 2023-02-09
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Harrisonburg, VA
Sunnyside Presbyterian Retirement Community
5-star overall rating with 5-star inspections with 2 recent health deficiencies
3935 Sunnyside Drive, Suite A, Harrisonburg, VA
(540) 568-8200
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
69
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.58
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.27
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
30%
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
713
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65
Composite VBP score used to determine payment impact.
Payment multiplier
1.0193
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.88
Baseline 21.23% · Performance 18.25% · Measure score 6.88 · Achievement 6.88 · Improvement 6.61
Healthcare-associated infections
10
Baseline 6.26% · Performance 4.57% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.23
Baseline 50.00% · Performance 50.50% · Measure score 3.23 · Achievement 3.23 · Improvement 0
Adjusted total nurse staffing
5.9
Baseline 3.40 hours · Performance 4.76 hours · Measure score 5.9 · Achievement 5.9 · Improvement 5.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 204 · Observed rate 8.82% · Lower 95% interval 7.44% |
| Discharge to community | 62.05% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 190 · Observed rate 62.63% · Lower 95% interval 56.64% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 149 · Denominator 149 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 149 |
| Discharge self-care score | 62.2% |
53.69%
8.5 pts better
|
Numerator 79 · Denominator 127 |
| Discharge mobility score | 58.27% |
50.94%
7.3 pts better
|
Numerator 74 · Denominator 127 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 149 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 4.57% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 0% · Lower 95% interval 2.53% |
| Staff COVID-19 vaccination coverage | 65.99% |
8.2%
57.8 pts better
|
Numerator 97 · Denominator 147 |
| Staff flu vaccination coverage | 13.46% |
42%
28.5 pts worse
|
Numerator 44 · Denominator 327 |
| Discharge function score | 74.02% |
56.45%
17.6 pts better
|
Numerator 94 · Denominator 127 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 89 · Denominator 89 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 41.77% |
25.2%
16.6 pts better
|
Numerator 33 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
91.2%
5.5 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 98.1% · Q3 100.0% · Q4 98.2% · 4Q avg 96.7% |
| 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 | 9.9% |
3.6%
6.3 pts worse
|
3.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.3% · Q3 11.8% · Q4 8.8% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
15.7%
15.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.7%
0.8 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 7.0% · Q3 4.7% · Q4 3.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.2% |
20.2%
14 pts worse
|
19.6%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 38.6% · Q3 33.3% · Q4 30.2% · 4Q avg 34.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
15.0%
0.6 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 12.9% · Q3 11.4% · Q4 9.5% · 4Q avg 14.4% · 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 | 39.3% |
17.5%
21.8 pts worse
|
16.3%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 29.2% · Q4 39.5% · 4Q avg 39.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.4% |
15.7%
20.7 pts worse
|
14.9%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 45.9% · Q3 36.8% · Q4 34.0% · 4Q avg 36.4% · 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 | 2.9% |
1.6%
1.3 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.7% · Q3 2.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.0% |
22.2%
8.8 pts worse
|
19.8%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 41.9% · Q3 40.4% · Q4 21.5% · 4Q avg 31.0% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.2%
2.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.2% · Q3 3.0% · Q4 1.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
74.6%
14.4 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.3% · Q2 87.0% · Q3 93.8% · Q4 89.4% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.7%
3.5 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.4% · Expected 10.1% · 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 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
73.6%
20.8 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.0%
2.2 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 20.0% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-20 · Fire 2021-05-20
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-04-25 · Fire 2019-04-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-05-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-20
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-06-09
D · Potential for more than minimal harm
2019-04-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-04-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-04-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-04-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-04-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-02-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-02-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-05-12
E · Potential for more than minimal harm
2021-05-20
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 2021-06-15
D · Potential for more than minimal harm
2021-05-20
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 2021-06-15
D · Potential for more than minimal harm
2019-04-25
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 2019-05-14
D · Potential for more than minimal harm
2019-04-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-05-14
D · Potential for more than minimal harm
2019-04-25
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 2019-05-14
D · Potential for more than minimal harm
2019-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-14
D · Potential for more than minimal harm
2019-04-25
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-05-14
Penalties and ownership
What sits behind the stars
Ownership
Lyons, Joshua
W-2 Managing Employee · Individual
Morin, Richard
Corporate Director · Individual
Rowe, James
Corporate Director · Individual
Sibold, Charlotte
Corporate Director · Individual
Nearby options
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#2
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1-star overall rating with 1-star inspections with abuse icon flag with $119,223 in total fines with 42 recent health deficiencies
#3
Vmrc, Complete Living Care
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4-star overall rating with 4-star inspections with 5 recent health deficiencies
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