F54

HARRISONBURG HLTH & REHAB CNTR

Grade F 54/100 composite score

Government - FederalAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
4/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

180

Ownership

Government - Federal

Total Fines

$119,223

Last Survey

N/A

1225 RESERVOIR STREET, HARRISONBURG, VA 22801
5404332623

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.24h
LPN
0.92h
CNA
1.59h
Total
2.75h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

HARRISONBURG HOLDINGS I LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2021

100%

AMERICA WEST LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

CHARLES 1994 & FAMILY LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

CHARLES 1994 FAMILY GRANTOR TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

CHARLES 1994 LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

EDWARD 1998 FAMILY GRANTOR TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

KSS 2000 FAMILY TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

ML 2000 FAMILY TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

MRV WEST LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

REDROCK WEST LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

SAUL 2012 FAMILY GRANTOR TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

SAUL 2012 LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2021

RCZBM WEST MANAGER LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2021

BROOKS, MATTHEW

IndividualW-2 MANAGING EMPLOYEESince Sep 2023

Penalties & Fines (1)

$119,223total fines
DateTypeDescriptionAmount
Apr 11, 2025Fine$119,223

Health Inspection Deficiencies (73)

September 24, 2025Health5 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 31, 2025
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

0804DMinimal harm, Isolated

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

0806DMinimal harm, Isolated

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies

June 5, 2025Health2 deficiencies
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 30, 2025
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Jun 30, 2025
April 11, 2025Health19 deficiencies4 severe
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jan 11, 2025
0600JImmediate jeopardy, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 21, 2025
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 21, 2025
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 21, 2025
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 21, 2025
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected May 21, 2025
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected May 21, 2025
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected May 21, 2025
0689KImmediate jeopardy, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 21, 2025
0690GActual harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected May 21, 2025
0692GActual harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected May 21, 2025
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 30, 2025
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected May 21, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 21, 2025
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected May 21, 2025
0925FMinimal harm, Widespread

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Corrected May 21, 2025
0943DMinimal harm, Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 21, 2025
0945DMinimal harm, Isolated

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Infection Control Deficiencies

Corrected May 21, 2025
0949EMinimal harm, Pattern

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies

Corrected May 21, 2025
July 2, 2024Health2 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Aug 6, 2024
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Aug 6, 2024
January 17, 2024Health2 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 16, 2024
0699DMinimal harm, Isolated

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Corrected Feb 16, 2024
August 23, 2023Health2 deficiencies
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Sep 26, 2023
0773DMinimal harm, Isolated

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Administration Deficiencies

Corrected Sep 26, 2023
May 26, 2022Health16 deficiencies
0567EMinimal harm, Pattern

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Corrected Jun 28, 2022
0576CNo harm, Widespread

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies

Corrected Jun 28, 2022
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Jun 28, 2022
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 28, 2022
0644EMinimal harm, Pattern

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 28, 2022
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jun 28, 2022
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 28, 2022
0740EMinimal harm, Pattern

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Corrected Jun 28, 2022
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 28, 2022
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jun 28, 2022
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Jun 28, 2022
0760EMinimal harm, Pattern

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Jun 28, 2022
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jun 28, 2022
0800EMinimal harm, Pattern

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Nutrition and Dietary Deficiencies

Corrected Jun 28, 2022
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 28, 2022
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Jun 28, 2022
April 22, 2021Health8 deficiencies
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 1, 2021
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 1, 2021
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Jun 1, 2021
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0908BNo harm, Pattern

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Jun 1, 2021
May 2, 2019Health17 deficiencies
0883DMinimal harm, Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Jun 4, 2019
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jun 4, 2019
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jun 4, 2019
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 4, 2019
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 4, 2019
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 4, 2019
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Jun 4, 2019
0657EMinimal harm, Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 4, 2019
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jun 4, 2019
0687DMinimal harm, Isolated

Provide appropriate foot care.

Quality of Life and Care Deficiencies

Corrected Jun 4, 2019
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 4, 2019
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Jun 4, 2019
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Jun 4, 2019
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Jun 4, 2019
0757EMinimal harm, Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Jun 4, 2019
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jun 4, 2019
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 4, 2019

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Frequently Asked Questions

What is the CareGrader rating for HARRISONBURG HLTH & REHAB CNTR?

HARRISONBURG HLTH & REHAB CNTR in HARRISONBURG, Virginia has a CareGrader grade of F (Poor), with a composite score of 53.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for HARRISONBURG HLTH & REHAB CNTR?

HARRISONBURG HLTH & REHAB CNTR has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does HARRISONBURG HLTH & REHAB CNTR have?

HARRISONBURG HLTH & REHAB CNTR has 73 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has HARRISONBURG HLTH & REHAB CNTR been fined?

Yes. HARRISONBURG HLTH & REHAB CNTR has $119,223 in total fines from CMS enforcement actions across 1 penalty.

How many beds does HARRISONBURG HLTH & REHAB CNTR have?

HARRISONBURG HLTH & REHAB CNTR has 180 certified beds with approximately 157 current residents (87% occupancy). The facility is located at 1225 RESERVOIR STREET, HARRISONBURG, Virginia 22801. It is a government - federal facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.