Harrisonburg HLTH & Rehab CNTR

In the surveyor’s words

From the most serious findings on record at Harrisonburg HLTH & Rehab CNTR, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Feb 13, 2026

  Based on observations, staff and resident interviews and facility document review, the facility staff failed to maintain a safe environment for two of forty-three residents in the survey sample (Resident #108 and Resident #142). One oxygen cylinder was observed free-standing, unsecured constituting the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity resulting in substandard quality of care. Upon verification of the removal of the IJ, the scope and severity were lowered to Level Two, Isolated. The facility also failed to ensure an electric space heater was not used as a primary source of heat for one of forty-three residents (Resident #80). […]

• Immediate jeopardy, patternF689Apr 11, 2025

  Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide adequate supervision and an environment free of accident hazards to prevent injury to residents, that resulted in two instances of injury/harm to Resident #12 (R12) and one occurrence of harm for Resident #18 (R18). Having the potential to affect multiple residents residing on three of three nursing units, the noncompliance resulted in the identification of immediate jeopardy (IJ) and substandard quality of care. The findings included: 1. […]

• Immediate jeopardy, isolatedF600Apr 11, 2025

  2. For Resident #10 (R10), the facility staff neglected to respond to the residents call for assistance to have incontinence care provided, which resulted in R10 being left to sit in feces for fifty minutes, which resulted in psychosocial harm. On 4/3/25 at 9:38 a.m., upon the surveyor's arrival to the south unit, it was noted that several call bells were engaged. A light could be seen outside of the rooms and an auditory sound could be heard beeping in the hallways. On 4/3/25 at 9:41 a.m., the surveyor entered the room of R10, whose call light was on. R10 acknowledged that he had his call light on and reported that he needed to be changed. When asked how long his call light had been on, R10 said, Go look for yourself. […]

• Actual harm, isolatedF690Apr 11, 2025

  3. For Resident #10 (R10), who suffered from quadriplegia and was totally dependent upon facility staff, the facility staff failed to respond to the call bell to provide incontinence care in a timely manner, resulting in psychosocial harm. On 4/3/25 at 9:38 a.m., upon the surveyor's arrival to the south unit, observations revealed multiple call bells/lights engaged. On 4/3/25 at 9:41 a.m., the surveyor entered the room where one of the call lights was engaged as evidenced by a light being illuminated outside the door in the hallway and a beeping auditory sound being heard. R10 acknowledged that he had his call light on and reported he needed to be changed. When asked how long his call light had been on, R10 said, Go look for yourself. […]

• Actual harm, isolatedF692Apr 11, 2025

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents maintain acceptable parameters of nutritional status for one resident (Resident #5) in a survey sample of 26 residents. The findings included: For Resident #5 (R5), who was admitted with a known significant weight loss, then lost 18 pounds in the first nine days at the facility, and lost 24 pounds in 5 weeks, the facility staff failed to implement interventions timely to prevent further significant weight loss. On 4/4/25 at 7:50 a.m., an interview was conducted with R5. R5 had his breakfast tray and observations revealed he had all items in bowls. […]