Deficiency Records for Lynchburg Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lynchburg Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-20 | 2023-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-06 | 2022-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-30 | 2022-04-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-30 | 2022-04-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-10 | 2022-03-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-30 | 2022-03-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-30 | 2022-03-30 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-30 | 2022-03-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-30 | 2022-03-30 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-11-30 | 2022-03-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-30 | 2022-03-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-30 | 2022-03-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-30 | 2022-03-30 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-11-30 | 2022-03-30 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-30 | 2022-03-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-30 | 2022-01-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-30 | 2022-01-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-30 | 2022-01-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-01 | 2021-10-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-01 | 2021-10-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-10-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-01 | 2021-10-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-01 | 2021-10-19 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-07-01 | 2021-10-19 | N |
| 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. | Health | 2021-07-01 | 2021-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-01 | 2021-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-09-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-01 | 2021-09-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-10 | 2021-09-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-10 | 2021-09-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-10 | 2021-09-21 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-08-10 | 2021-09-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-10 | 2021-09-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-01 | 2021-09-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-01 | 2021-09-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-01 | 2021-09-21 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-07-01 | 2021-09-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-01 | 2021-09-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-01 | 2021-08-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-01 | 2021-08-06 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-07-07 | 2021-07-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-18 | 2021-06-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-18 | 2021-06-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-17 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-17 | 2019-11-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-17 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-17 | 2019-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-17 | 2019-11-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-09-17 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-17 | 2019-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-17 | 2019-11-01 | N |
| 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. | Health | 2019-09-17 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-17 | 2019-11-01 | N |
| Meet other general requirements. | Fire Safety | 2019-09-25 | 2019-10-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-25 | 2019-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-13 | 2018-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-13 | 2018-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-13 | 2018-11-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-13 | 2018-11-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-13 | 2018-09-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-13 | 2018-09-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-13 | 2018-09-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-13 | 2018-09-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-08-13 | 2018-09-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-02 | 2018-08-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-02 | 2018-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-08-02 | 2018-08-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-02 | 2018-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-02 | 2018-08-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-02 | 2018-08-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-08-02 | 2018-08-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-02 | 2018-08-29 | N |
| 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. | Health | 2018-08-02 | 2018-08-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-02 | 2018-08-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-02 | 2018-08-29 | N |
