Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lynchburg Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and continuous O2 therapy had two care-related signs posted above the bed that were visible to anyone entering the room. The signs included instructions about the bed control and checking the concentrator/O2 tank. The resident said they did not know why the signs were there, and the DON confirmed there was no documentation that the resident or family requested the signage.
MDS assessments were coded inaccurately for two residents’ medication use and one resident’s hearing status. One resident receiving clopidogrel was coded as receiving an anticoagulant instead of an antiplatelet, another resident on Rexulti was coded with a pre-admission GDR contraindication date, and a resident with documented bilateral hearing loss and observed difficulty hearing was coded as having adequate hearing.
A resident with documented bilateral hearing loss and audiology-recommended hearing aids was not provided assistance or available hearing resources. Staff and family reported the resident could not afford hearing aids, but no follow-up was documented after the audiology visit, the MDS inaccurately reflected adequate hearing, and the resident continued to have difficulty hearing conversations and Resident Council meetings despite the facility having hearing amplifiers available.
Incomplete documentation of pressure-ulcer prevention care: A resident with HF, muscle wasting/atrophy, and encephalopathy had an air mattress and multi-podus boots in the care plan, but the record did not show the interventions were implemented, checked daily, or that the resident’s behavior of removing heel protection was documented. CNA staff said the resident was turned and repositioned every 2 hours and the air mattress was checked daily, and the DON confirmed the behavior and care were not recorded in the chart.
A facility failed to provide a resident and their representative with a written transfer notice during an urgent hospital transfer, as required by federal regulations. The facility's policy did not address the need for written notice in such cases, and the resident's EMR lacked documentation of the notice. Interviews confirmed the absence of a written notice.
The facility failed to invite two residents or their representatives to participate in quarterly care plan meetings, as required by policy. Despite having a process to notify families, the Social Services Director did not document invitations for these residents. One resident was cognitively intact, while the other had moderate cognitive intactness. The facility's policy did not specifically address quarterly care conferences, leading to this oversight.
Visible Medical Information Posted in Resident Room
Penalty
Summary
The facility failed to ensure medical information was not visible for Resident #47. The resident was admitted and readmitted with diagnoses including acute and chronic respiratory failure, depression, anxiety, and dementia. The care plan included congestive heart failure, oxygen via nasal cannula at 2 liters per minute continuously, and impaired cognition related to dementia. The quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment, and the resident received oxygen therapy at the facility. During observations in the resident’s room, surveyors found two signs posted above the bed that were visible to anyone entering the room. One sign instructed staff not to wrap the resident’s bed control around the bottom of the bed frame, and the other instructed staff to check the concentrator/O2 tank. The resident stated they did not know why the signs were there. The DON confirmed the signage was visible to anyone entering the room, was unaware who or why it was posted, and stated signage was not to be posted in resident rooms and visible to others unless requested by the resident or family. The DON also confirmed there was no documentation in the medical record showing the resident or representative had requested the signage.
MDS Coding Errors for Medications and Hearing Status
Penalty
Summary
The facility failed to accurately code MDS assessments for medication use for two residents and hearing status for one resident. Review of the CMS RAI Manual showed that clopidogrel is an antiplatelet medication and should not be coded as an anticoagulant, that antipsychotic coding requires review of whether a GDR was attempted or clinically contraindicated during the resident’s stay, and that hearing should be coded based on the resident’s actual hearing ability during the look-back period. For one resident with diagnoses including acute and chronic respiratory failure, atherosclerotic heart disease, aortic valve stenosis, hypertensive heart and chronic kidney disease with heart failure, and paroxysmal atrial fibrillation, the record showed clopidogrel was ordered and administered daily. The quarterly MDS assessments, however, coded the resident as receiving anticoagulant medication during the 7-day look-back period and did not code antiplatelet use. The MDS Coordinator confirmed clopidogrel is an antiplatelet, not an anticoagulant, and stated the assessments were not coded accurately. For another resident with dementia, major depressive disorder, and Alzheimer’s disease, the record showed an order for Rexulti for dementia and documentation that a GDR was clinically contraindicated dated before the resident’s admission to the facility. The quarterly MDS coded the resident as receiving antipsychotic medication on a routine basis with a documented clinically contraindicated GDR date that predated admission. For the third resident, who had documented bilateral hearing loss and an audiology evaluation showing moderate to severe hearing loss with hearing aids recommended, the quarterly MDS coded adequate hearing despite the resident’s statements and observations showing difficulty hearing and needing repeated communication. The MDS Coordinator confirmed the hearing code was incorrect and should have reflected hearing loss.
Failure to Assist Resident With Hearing Services
Penalty
Summary
The facility failed to provide assistance or use available resources related to hearing loss for one resident with documented bilateral hearing loss. The resident was admitted with diagnoses including heart failure, diabetes, and peripheral vascular disease, and an audiology visit showed moderate to severe hearing loss in the right ear and moderate to profound hearing loss in the left ear, with hearing aids recommended. A later MDS assessment inaccurately indicated the resident had adequate hearing, despite the resident being cognitively intact with a BIMS score of 15 and having a diagnosis of bilateral hearing loss added to the medical record. During interviews and observations, the resident stated she could not hear well, had trouble hearing church singing, and had been told about hearing aids about a year earlier but had not heard anything further. Staff observed the resident having difficulty hearing during a conversation and during a Resident Council meeting, requiring frequent repetition and rewording to understand what was said. The Activities Director acknowledged the resident was very hard of hearing, the LPN/UCC believed the family could not afford hearing aids, and the daughter confirmed she had not been offered help finding alternatives or other resources. The Social Service Director confirmed there was no documentation of follow-up after the audiology testing and that hearing amplifiers were available in the facility but had not been provided to the resident.
Incomplete Documentation of Pressure-Ulcer Prevention Care
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for one resident whose record was reviewed. The resident was admitted with diagnoses including heart failure, muscle wasting/atrophy, and encephalopathy, and had been hospitalized from [DATE] to 6/12/2025. Review of the record from 6/12/2025 to 12/4/2025 showed no documentation that pressure-ulcer prevention interventions in the care plan, including an air mattress and multi-podus boots to both feet, had been implemented, no documentation that these interventions were checked daily for proper placement, and no documentation of the resident’s behaviors related to removing heel protectors or multi-podus boots. Observations on 11/1/2025, 11/2/2025, and 11/3/2025 showed the resident in bed with an air mattress and multi-podus boots in place while positioned on the back, left side, and right side at different times. CNA staff stated the resident had previously used heel booties, then heel boots, that the resident was turned and repositioned every two hours, and that the air mattress was checked daily, but these actions were not documented in the medical record. The DON confirmed the resident’s behavior of kicking off heel protection was not recorded and stated such behaviors should be documented, and the Executive Director confirmed the record should contain accurate and complete documentation of the care provided.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding a transfer to a hospital, as required by federal regulations. The facility's policy on transfers and discharges, dated 05/12/23, did not include provisions for issuing a written transfer notice in cases of urgent medical need. This oversight was identified during a review of the facility's policy and the electronic medical record (EMR) of a resident who was hospitalized following a fall and a subsequent change in condition. The resident, identified as R18, was admitted to the facility and later experienced a fall, which was documented in a progress note dated 07/17/23. Following a change in the resident's condition on 07/19/23, they were transported to a local hospital for evaluation and treatment. However, the EMR lacked evidence of a written transfer notice being provided to the resident or their representative, detailing the transfer location and appeal rights. Interviews with the resident's family member and the facility administrator confirmed that no written notice was given during the urgent transfer.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, R1 and R18, or their representatives were invited to participate in their quarterly care plan meetings. This deficiency was identified through a review of facility policy, medical records, and interviews. The facility's policy on comprehensive care plans, dated 08/22/23, mandates that residents and their representatives be given advance notice of care planning conferences to facilitate their participation. However, for R1, there was no documentation in the electronic medical record (EMR) indicating that the resident or her representative was invited to participate in quarterly care conferences after an initial update on 02/21/24. R1, who was cognitively intact with a BIMS score of 15 out of 15, confirmed during an interview that she was not invited to her quarterly care conferences. Similarly, for R18, the EMR showed that the resident's representative participated in a care conference on 02/08/24, but there was no evidence of invitations to subsequent quarterly care conferences. R18 had a BIMS score of eight out of 15, indicating moderate cognitive intactness. The Social Services Director (SSD) stated that her process involved calling and sending follow-up letters to families about upcoming care conferences, but she admitted to not documenting these invitations for R1 and R18. The facility's administrator acknowledged that the care conference policy did not address quarterly care conferences, contributing to the oversight.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lynchburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Tullahoma | 9.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Tullahoma | 9.5 mi | ★★★★★ | 5 | 0 |
| Donalson Care Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Elk River Health & Rehabilitation Of Fayetteville | 14.6 mi | ★★★★★ | 16 | 0 |
| The Waters Of Shelbyville, Llc | 14.7 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lynchburg Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.