Cycle 1
Health 2023-03-15 · Fire 2023-03-15
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Harrisonburg, VA
Vmrc, Complete Living Care
4-star overall rating with 4-star inspections with 5 recent health deficiencies
1475 Virginia Avenue, Harrisonburg, VA
(540) 564-3500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
110
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-10-28
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
0.62
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
4.44
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.88
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
5.43
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.53
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
0.68
CMS adjusted RN staffing hours
Adjusted total hours
6.46
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
153
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
81.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0261
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.52
Baseline 18.76% · Performance 18.41% · Measure score 6.52 · Achievement 6.52 · Improvement 1.52
Healthcare-associated infections
7.79
Baseline 3.20% · Performance 5.51% · Measure score 7.79 · Achievement 7.79 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Baseline 5.67 hours · Performance 6.77 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 473 · Observed rate 7.82% · Lower 95% interval 7.04% |
| Discharge to community | 66.89% |
50.57%
16.3 pts better
|
Better than the National Rate · Eligible stays 469 · Observed rate 67.8% · Lower 95% interval 63.11% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 93.43% |
95.27%
1.8 pts worse
|
Numerator 256 · Denominator 274 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 274 |
| Discharge self-care score | 59.27% |
53.69%
5.6 pts better
|
Numerator 147 · Denominator 248 |
| Discharge mobility score | 52.82% |
50.94%
1.9 pts better
|
Numerator 131 · Denominator 248 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 5 · Denominator 274 · Adjusted rate 2.59% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 239 · Observed rate 3.35% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0.36% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 276 |
| Staff flu vaccination coverage | 42.32% |
42%
0.3 pts better
|
Numerator 226 · Denominator 534 |
| Discharge function score | 64.11% |
56.45%
7.7 pts better
|
Numerator 159 · Denominator 248 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 99.5% |
96.28%
3.2 pts better
|
Numerator 200 · Denominator 201 |
| Resident COVID-19 vaccinations up to date | 26.8% |
25.2%
1.6 pts better
|
Numerator 41 · Denominator 153 |
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 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
91.2%
1.9 pts worse
|
93.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.5% · Q2 96.4% · Q3 97.7% · Q4 98.8% · 4Q avg 89.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.0%
4.9 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.6%
2.4 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.1% · Q3 3.5% · Q4 7.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
15.7%
14.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.7%
1.8 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 4.1% · Q3 6.8% · Q4 10.7% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
20.2%
5.5 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 10.1% · Q3 14.5% · Q4 23.1% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
15.0%
6.4 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.6% · Q3 9.0% · Q4 10.0% · 4Q avg 8.6% · 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 | 27.6% |
17.5%
10.1 pts worse
|
16.3%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 26.2% · Q3 27.0% · Q4 28.7% · 4Q avg 27.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.7% |
15.7%
13 pts worse
|
14.9%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 26.7% · Q3 28.8% · Q4 25.7% · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.5%
0.6 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 0.0% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.6%
0.6 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.4% · Q4 3.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
22.2%
4.8 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 26.9% · Q3 25.3% · Q4 22.1% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
5.2%
3.1 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.3% · Q3 8.1% · Q4 11.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
74.6%
21.5 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 95.8% · Q3 98.0% · Q4 96.5% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
11.7%
3.3 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 7.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
73.6%
23.4 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
22.0%
About the same
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 18.7% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-21 · Fire 2021-07-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-29 · Fire 2018-11-29
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-07-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-05
D · Potential for more than minimal harm
2021-07-21
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-08-05
D · Potential for more than minimal harm
2018-11-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-03-12
D · Potential for more than minimal harm
2018-11-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-03-12
D · Potential for more than minimal harm
2018-11-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-02-11
D · Potential for more than minimal harm
2018-11-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-02-11
D · Potential for more than minimal harm
2018-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-11
D · Potential for more than minimal harm
2018-11-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-02-11
D · Potential for more than minimal harm
2018-11-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-02-11
D · Potential for more than minimal harm
2018-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-02-11
D · Potential for more than minimal harm
2018-11-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-02-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-03-15
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 2023-05-12
E · Potential for more than minimal harm
2023-03-15
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 2023-05-12
D · Potential for more than minimal harm
2023-03-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-12
C · Minimal harm
2023-03-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-05-12
D · Potential for more than minimal harm
2021-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-20
F · Potential for more than minimal harm
2018-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-11
E · Potential for more than minimal harm
2018-11-29
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 2019-01-11
D · Potential for more than minimal harm
2018-11-29
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-11-29
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 2019-01-11
D · Potential for more than minimal harm
2018-11-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-01-11
Penalties and ownership
What sits behind the stars
Ownership
Bell, Donald
Operational/Managerial Control · Individual
Bell, Donald
Corporate Officer · Individual
Bert, Daryl
Operational/Managerial Control · Individual
Bert, Daryl
Corporate Director · Individual
Blosser, Kelly
Operational/Managerial Control · Individual
Blosser, Kelly
Corporate Director · Individual
Blosser, Myron
Operational/Managerial Control · Individual
Blosser, Myron
Corporate Director · Individual
Boshart-Yoder, Teresa
Operational/Managerial Control · Individual
Boshart-Yoder, Teresa
Corporate Director · Individual
Hartman, Jacqueline
Operational/Managerial Control · Individual
Hartman, Jacqueline
Corporate Director · Individual
Hollar, Hunter
Operational/Managerial Control · Individual
Hollar, Hunter
Corporate Director · Individual
King, Debra
Operational/Managerial Control · Individual
King, Debra
Corporate Director · Individual
Piper, Michael
Operational/Managerial Control · Individual
Piper, Michael
Corporate Officer · Individual
Seitz, Randy
Operational/Managerial Control · Individual
Seitz, Randy
Corporate Director · Individual
Smucker, David
Operational/Managerial Control · Individual
Smucker, David
Corporate Director · Individual
Thorpe, Rebecca
Operational/Managerial Control · Individual
Thorpe, Rebecca
Corporate Officer · Individual
Virginia Mennonite Retirement Community Inc
Operational/Managerial Control · Organization
Yoder, Laura
Operational/Managerial Control · Individual
Yoder, Laura
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Sunnyside Presbyterian Retirement Community
Harrisonburg, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Harrisonburg Hlth & Rehab Cntr
Harrisonburg, VA
1-star overall rating with 1-star inspections with abuse icon flag with $119,223 in total fines with 42 recent health deficiencies
#3
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
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