Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Liberty Ridge Health & Rehab during CMS and state inspections, most recent first.
A medication administration error occurred when an RN prepared medications for one resident and an LPN administered them to another, resulting in harm. The affected resident was hospitalized with acute metabolic encephalopathy and other complications due to receiving medications not prescribed for her. The error was recognized immediately, and the resident was treated and stabilized before returning to the facility.
A medication error occurred when a nurse in orientation prepared medications for one resident, but another nurse administered them to the wrong resident, leading to hospitalization. The resident, with severe cognitive impairment and multiple health conditions, received medications not prescribed for her, resulting in acute metabolic encephalopathy and other complications.
The facility staff did not follow the posted menu, affecting residents on both nursing units. Residents reported discrepancies between the meals served and the menu. The cook substituted broccoli for greens without proper documentation or approval. The substitution log was outdated, and the registered dietician confirmed that substitutions were not being reviewed for nutritional equivalence. The facility's policy on menu changes was not adhered to, and the administrator and DON were informed of these issues.
The facility failed to serve food at appetizing temperatures, affecting multiple residents. Residents reported lukewarm food and coffee, and observations confirmed that food temperatures were below recommended levels. The dietary manager acknowledged the issue, citing the nature of breakfast foods. Facility policies and FDA guidelines emphasize maintaining proper food temperatures to prevent foodborne illness.
The facility staff failed to adhere to food safety standards, with issues in food storage, labeling, and dish drying. Open and unlabeled dry goods were found in the kitchen, and expired milk was available for resident consumption. Additionally, wet dishes were improperly stacked, risking bacterial growth. These deficiencies highlight lapses in following established food safety protocols.
The facility failed to limit PRN psychotropic medication orders for two residents, resulting in orders for Ativan and Seroquel being active beyond the 14-day limit. Staff interviews and record reviews confirmed the oversight, and the facility lacked a policy for PRN psychotropic medications. The DON acknowledged the requirement for a 14-day limit, which was not followed.
The facility failed to accurately label a medication and discard an expired medication on the skilled unit. A resident received metoprolol with an incorrect label, as the pharmacy did not update the dosage change. Additionally, an expired psyllium husk powder was found in the medication cart, which the LPN acknowledged and removed. The facility's policy requires expired medications to be stored separately until destroyed or returned.
A facility failed to maintain an accurate clinical record for a resident, resulting in the misfiling of another resident's advance directive form. The error involved a resident's record containing a Durable Do Not Resuscitate Order, while mistakenly including a full code status form for another resident. The social services department was responsible for the error, which was confirmed by the social services director. The issue was discussed with facility leadership, but no additional information was provided before the survey ended.
The facility failed to update the grievance officer's information on postings, leaving residents unaware of whom to contact for grievances. During a resident meeting, several residents expressed their lack of knowledge about the grievance officer. Observations confirmed outdated postings, and interviews with staff revealed they were unaware of the issue. The administrator, who had been the grievance officer for years, confirmed the discrepancy.
Medication Administration Error Leads to Resident Harm
Penalty
Summary
The facility staff failed to adhere to professional standards of practice during medication administration, resulting in harm to a resident. The incident involved the administration of medications intended for one resident to another resident, who was her roommate. This error occurred when a registered nurse (RN) prepared the medications for the intended resident and handed them to a licensed practical nurse (LPN), who then administered them to the wrong resident. The error was immediately recognized, and the affected resident was sent to the emergency room for treatment. The resident who received the incorrect medications suffered significant harm, requiring hospitalization. The medications administered in error included several that were not prescribed for her, leading to acute metabolic encephalopathy, supratherapeutic INR, and accidental poisoning by benzodiazepines and digoxin. The resident was treated in the emergency room with atropine, intravenous fluids, and other interventions before being stabilized and discharged back to the facility. Interviews with the involved staff revealed that the error was due to a lapse in following the fundamental nursing practice of ensuring the '5 rights' of medication administration. The RN was in the process of orienting to the medication cart and handed off the medications to the LPN, who administered them without verifying the correct resident. Both staff members were aware of the error immediately after it occurred, and the facility's policy on medication administration was not followed, leading to the resident's harm.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, resulting in harm. A nurse prepared medications intended for one resident but handed them to another nurse, who then administered them to the wrong resident. This error led to the resident receiving multiple medications not prescribed for her, causing her to be hospitalized. The resident involved had a medical history that included dementia, muscle weakness, hypertension, major depressive disorder, long-term use of anticoagulants, and chronic atrial fibrillation. The resident was assessed with severe cognitive impairment. After receiving the incorrect medications, the resident was transferred to the emergency room, where she was treated for acute metabolic encephalopathy, supratherapeutic INR, accidental clonazepam poisoning, and accidental digoxin overdose. The incident occurred when a registered nurse, who was in orientation, prepared the medications and handed them to a licensed practical nurse, who then administered them to the wrong resident. The error was immediately recognized, and the resident was sent to the emergency room for treatment. Interviews with the involved staff revealed that the error was due to one nurse preparing the medications and another administering them, which was against the facility's policy of ensuring the 5 rights of medication administration.
Failure to Follow Posted Menu and Document Substitutions
Penalty
Summary
The facility staff failed to adhere to the posted menu, which affected residents on both nursing units. During a resident council meeting, residents expressed that the meals served did not match the posted menu. Observations confirmed that the evening meal listed on the menu was chicken tenders, seasoned greens, macaroni and cheese, and a fresh fruit cup. However, the cook was preparing broccoli instead of greens due to unavailability. The cook was unaware of the requirement for a substitution log or the need for approval when making menu changes. The dietary manager acknowledged the existence of a substitution log, but it had not been updated since February 2022. The registered dietician confirmed that substitutions should be recorded and reviewed to ensure nutritional equivalence, which was not being done. The facility's policy mandates that all menu changes be documented and reviewed by the dietician, but this was not followed. The facility administrator and DON were informed of these issues, but no additional information was provided.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to provide foods at appetizing temperatures on two nursing units, affecting multiple residents. During a resident council meeting, residents expressed that the food served was not hot. An interview with a resident revealed that the food and coffee were lukewarm, and while they could request reheating, it involved waiting. Observations in the kitchen showed that coffee was brewed, cooled with ice, and then placed in dispensers for distribution. During breakfast service, a test tray was prepared and placed on the last meal cart, which was for the 100 hall. The test tray was swapped with a resident tray, and the temperatures of the foods were taken, revealing that the milk, coffee, eggs, oatmeal, and biscuit were all below the recommended temperatures. The dietary manager acknowledged that the temperatures were low but attributed it to the nature of breakfast foods. A review of the facility's food policies indicated that hot food should be palatable at the point of delivery, with a goal temperature of 130-155 degrees Fahrenheit when served. The Food and Drug Administration's Food Code 2017 emphasizes the importance of maintaining proper holding temperatures to prevent foodborne illness. The facility administrator and director of nursing were informed of these findings during an end-of-day meeting.
Food Safety and Storage Deficiencies in Facility
Penalty
Summary
The facility staff failed to store and prepare food in accordance with food safety standards, as observed during a survey. In the main kitchen, dry storage items such as pasta, brown sugar, and cereal were found open to air and not labeled with dates of opening or use-by dates. The dietary manager was unsure about the labeling requirements for dry goods, and the registered dietician confirmed that all items should be closed and dated. The facility's policy on dry food storage was not adhered to, as it required opened food to be stored in durable, leak-proof containers with proper labeling. Additionally, the facility staff did not ensure that expired food items were removed from storage and not available for serving to residents. During an inspection, expired milk was found in the walk-in cooler and on the tray line for breakfast service. The dietary aide was unaware of the expired milk, and the dietary manager discarded it upon discovery. The facility's food storage policies did not address the use of expired food items, which is a critical oversight in maintaining food safety. The facility staff also failed to properly dry dishes, which could lead to microorganism growth. Observations revealed that a dietary aide was stacking wet dishes immediately after removing them from the dishwasher, resulting in water pooling in the bowls. This practice, known as wet nesting, was acknowledged by the dietary manager as a potential risk for bacterial growth. The facility's policy required dishes to be air-dried before stacking, but this was not followed, leading to a breach in food safety protocols.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility staff failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident #70, the facility did not limit the order for the antianxiety medication Ativan to 14 days as required for PRN psychotropic medications. The order, written on 4/15/24, remained active without a stop date at the time of the survey. Interviews with staff confirmed the oversight, and the Director of Nursing (DON) acknowledged the requirement for a 14-day limit on PRN orders, which was not followed. The facility also lacked a policy related to PRN orders for psychotropic medications. Resident #67 had a PRN order for the antipsychotic medication Seroquel, which was entered without a stop date and remained active beyond the 14-day limit. The order was in place for 30 days before being discontinued following a pharmacy recommendation. The clinical record lacked documentation of assessments justifying the extended use of Seroquel. The DON confirmed the order was entered without a stop date upon the resident's admission and was not discontinued until later. The Nursing 2022 Drug Handbook notes that Seroquel carries a Black Box Warning for increased risk of death in elderly patients with dementia-related psychosis, highlighting the importance of adhering to guidelines for psychotropic medication use.
Medication Labeling and Expired Medication Issues
Penalty
Summary
The facility staff failed to accurately label a medication and discard an expired medication on the skilled unit. During a medication pass observation, it was found that the medication metoprolol administered to Resident #132 was labeled with an incorrect dosage. The pharmacy supply card indicated a dosage of 25 mg twice per day, while the physician's order dated 5/30/24 specified a dosage of 12.5 mg twice per day. The licensed practical nurse (LPN) administering the medication was aware of the dosage change but stated that the pharmacy had not provided the updated label or new supply of half tablets. The pharmacy manager confirmed the dosage change and explained that the insurance company did not approve a new supply, requiring the facility to cut the tablets in half. However, the pharmacy did not have a written policy for using dose change alert stickers, which were available to notify nursing staff of such changes. Additionally, during a medication storage review, an expired medication was found on the skilled unit. A bottle of psyllium husk powder with a manufacturer's expiration date of 3/24 was discovered in the medication cart. The LPN acknowledged that the medication should have been discarded and removed it from the cart. The facility's policy on storage and expiration dating of medications requires that expired, contaminated, or deteriorated medications be stored separately until destroyed or returned to the pharmacy. This information was presented to the director of nursing and the administrator, but no further information was provided before the survey's conclusion.
Inaccurate Clinical Record Due to Misfiled Advance Directive
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for one resident in the survey sample. A resident was admitted with diagnoses including anemia, atrial fibrillation, diabetes, and arthritis, and was assessed as cognitively intact. The resident's clinical record contained a Durable Do Not Resuscitate Order signed by both the physician and the resident. However, the record also mistakenly included an Advance Care Planning Tracking Form for another resident, which documented a verified full code status. This error was identified during an interview with the medical records clerk, who indicated that the social services department was responsible for entering resuscitation status forms into clinical records. The social services director confirmed that the form for the other resident was incorrectly scanned and entered into the wrong clinical record. This issue was discussed with the facility's administrator, director of nursing, and regional consultant, but no further information was provided before the survey concluded. The deficiency highlights a lapse in the facility's process for maintaining accurate and resident-specific medical records, which is crucial for ensuring appropriate care decisions are made based on each resident's documented wishes.
Failure to Update Grievance Officer Information
Penalty
Summary
The facility staff failed to update the grievance officer's information on postings in the common areas of two nursing units, which led to residents being unaware of whom to contact to file a grievance. During a resident council group meeting, seven residents expressed that they did not know who the grievance officer was, indicating a lack of communication and information dissemination regarding grievance procedures. Observations confirmed that the postings at the nurse's stations on each unit still listed a former staff member as the grievance officer, despite this individual no longer being employed at the facility. Interviews with the Director of Nursing, an LPN, and the unit manager revealed that they were unaware of the outdated information and did not recognize the name of the listed grievance officer. The facility administrator, who had been the grievance officer for over four years, confirmed the discrepancy during an end-of-day meeting. A review of the facility's documentation showed that the policy required the grievance officer's contact information to be prominently posted, but this had not been updated, leading to the deficiency.
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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.
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Nursing homes near Lynchburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynchburg Health & Rehabilitation Center | 2.4 mi | ★★★★★ | 5 | 0 |
| Summit Health And Rehab Center | 3.8 mi | ★★★★★ | 2 | 0 |
| Guggenheimer Health And Rehab Center | 5.1 mi | ★★★★★ | 3 | 0 |
| Forest Health & Rehab Center | 5.3 mi | ★★★★★ | 1 | 0 |
| Tate Springs Health & Rehab | 5.4 mi | ★★★★★ | 0 | 0 |
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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.