Harrisonburg Hlth & Rehab Cntr

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility staff failed to develop a care plan for one of eleven residents in a survey sample.Resident #4 (Resident R4) did not have a care plan for bowel incontinence.The findings included: Resident #4 (Resident R4) diagnoses include diabetes, congestive heart failure, respiratory failure, and peripheral vascular disease. The most recent MDS was a quarterly assessment dated [DATE REDACTED]. Resident R4 was assessed with a cognitive score of 15 indicating cognitively intact. Section H of Resident R4's MDS indicated Resident R4 is incontinent of bowel.On 9/22/25 at 2:30 p.m. Resident R4 was interviewed. Resident R4 verbalized being incontinent of bowel explaining numbness from the waist down and could not tell if a bowel movement had occurred and needed to be checked on frequently. Review of Resident R4's care plan did not indicate that Resident R4 had a care plan in place for bowel incontinence. On 9/22/25 3:15 p.m. certified nursing assistant CNA #1 was interviewed. CNA #1 verbalized taking care of Resident R4 on a regular basis and will check Resident R4 for bowel incontinence about every two hours, saying that Resident R4 has no feeling from the waist down. On 9/23/25 at 9:50 a.m. registered nurse (RN #1, MDS coordinator) was interviewed regarding Resident R4 being incontinent of bowel. MDS reviewed the care plan and agreed that a bowel incontinence care plan should have been put in place but was missed. On 9/23/25 at 3:30 p.m. the above finding was presented to the administrator and director of nursing.No other information was provided prior to the exit conference on 9/23/25.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harrisonburg Hlth & Rehab Cntr

1225 Reservoir Street Harrisonburg, VA 22801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

end of the night shift. On 9/23/25 at 1:35 p.m., the director of nursing (DON) was interviewed about Resident R5's incontinence care during the early morning shift on 6/7/25. The DON stated CNA #6 reported to LPN #5 that Resident R5 was found with a heavily soiled brief around 8:00 a.m. on 6/7/25. The DON stated CNA #7 that cared for Resident R5 on the prior shift was immediately suspended and a report sent to the state agency. The DON stated their investigation supported evidence that CNA #7 had not provided timely incontinence care for Resident R5 prior to shift change on the early morning of 6/7/25. The DON stated Resident R5's roommate (Resident #8) reported that CNA #7 came to the room but did not provide a brief change for Resident R5 prior to the end of the shift. The DON stated a skin assessment for Resident R5 following the reported lack of incontinence care indicated no skin issues.Resident R5's plan of care (revised 6/23/25) documented the resident was incontinent of bowel/bladder due to weakness and BPH. Interventions to keep the resident clean/dry included one-person assistance with toileting, checking and changing briefs frequently as needed and providing hygiene with brief changes.The facility's investigation of the reported lack of incontinence care included documented statements dated 6/7/25 from CNA #6 and LPN #5 stating that Resident R5 was found at the start of the day shift with a heavily soiled brief and wet bed linens, indicating lack of brief change. An interview with Resident R5's roommate (Resident #8) dated 6/7/25, documented the roommate reported CNA #7 provided him care but CNA #7 did not change Resident R5's brief during the last round of the shift.Residents #5 and #8 were not available for interview as they no longer resided in the facility.This finding was reviewed with the administrator, DON and regional nurse consultant during a meeting on 9/23/25 at 3:30 p.m. with no further information presented prior to the end of the survey.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harrisonburg Hlth & Rehab Cntr

1225 Reservoir Street Harrisonburg, VA 22801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

Administrator, and the Regional Director of Clinical Services. They were made aware of the above concerns.

No additional information was provided.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harrisonburg Hlth & Rehab Cntr

1225 Reservoir Street Harrisonburg, VA 22801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

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

Level of Harm - Minimal harm or potential for actual harm

Based on observation, resident interview, staff interview, and facility documentation the facility staff failed to serve a palatable meal to two residents, Resident #7 (Resident R7) and Resident #10 (Resident R10) out of a survey sample of eleven residents.The findings included:On 9/23/25 at 12:00 p.m., an observation was conducted during

the lunchtime meal service in the main dining room. During this observation, it was noted that several residents was not eating their meal. One resident complained about the temperature of the food. She stated that the food was not served hot and that is how she likes her food.On 9/23/25 at 12:11 p.m., a test tray was conducted. The tray served included: baked ham, mixed vegetables, scalloped potatoes, a roll, and a brownie. Food temperatures were taken with the following results:Baked ham: 121.6 FScalloped potatoes: 138.4 FMixed vegetables: 129.7 FRoll and brownie: served at room temperatureFor comparison, temperatures obtained in the kitchen prior to service were:Baked ham: 180 FScalloped potatoes: 190 FMixed vegetables: 183 FThe test tray food items were noted as lukewarm. The ham, potatoes, and vegetables were not served at an appetizing temperature. The vegetables were also reported to be very soft, bland, and lacking seasoning. The potatoes were bland and needed seasoning.The dietary manager was present during the test tray tasting and commented: Ham: good, Potatoes: delightful, and Mixed vegetables: it's veggies.An interview was not conducted with Resident R7 because she was no longer a resident at

the facility.On 9/23/25 at 11:45 a.m., an interview was conducted with Resident R10. She stated that her meals were never served hot. She stated that she liked her meals served hot and not lukewarm or cold.On 9/23/25 at 2:05 p.m., an interview with the dietary manager was conducted. He stated: Everything we serve needs to be less than 150 degrees, so no one is scalded. The temperature dropped significantly due to hot plates sitting and waiting to be served out there on the cart.On 9/23/25 the Facility documentation was reviewed.

The facility document titled, Quality and Palatability, read in part, It is the center policy that, food is prepared by methods that conserve nutritive value, flavor and appearance. Food is palatable, attractive and served at

a safe and appetizing temperature.On 9/23/25 at 3:45 p.m., an end-of-day meeting was held with the Director of Nursing (DON), the Administrator, and the Regional Director of Clinical Services. They were made aware of the above concerns.No additional information was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harrisonburg Hlth & Rehab Cntr

1225 Reservoir Street Harrisonburg, VA 22801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on observation, resident interview, staff interview and facility documentation the facility staff failed to provide the residents preference with the meals for three residents, Resident #9 (Resident R9), Resident #10 (Resident R10), and Resident #11 (Resident R11) out of a survey sample of eleven residents. The findings included: On 9/23/25 at 12:00 p.m., an observation was conducted during the lunchtime meal service in the main dining room.

During this observation, it was noted that three residents did not receive their stated meal preferences as listed on their meal tickets. Specifically, two residents, Resident R10 and Resident R11, had preferences for baked potato with meals and milk, and one resident, Resident R9 preferred dessert and milk. These preferences were not honored

during the lunch service. On 9-23-25 at 12:00 p.m., during the lunchtime meal service, resident interviews were conducted.Resident R9 stated, she never receives her dessert without having to ask for it and reported that she does not receive her milk with meals.Resident R10 stated, she does not receive her milk with meals and that condiments are not provided on her tray.R11stated, she likes milk but seldom receives it with her meals.

She also reported she seldom receives her baked potato as ordered.On 9/23/25 at 12:00 p.m., during an

interview in the dining room, the Certified Nursing Assistant, CNA#1 (CNA1) reviewed a meal ticket and stated he was unsure why the baked potato was not served, but he would check on it and provide one if available.On 9/23/25 a review of facility documentation was conducted. The document reviewed was titled, Menu. The policy states menus are planned in advance to meet the nutritional needs of residents/patients and are developed utilizing established national guidelines. It further states menus are to be served as written unless changes are made in response to resident preference, unavailability of an item, or for a special meal.On 9/23/25 at approximately 3:45 p.m., an end-of-day meeting was held with the Regional Director of Clinical Services, the Director of Nursing, and the Administrator. The above concerns were discussed. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet