Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Summit Health And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, which was documented by nursing staff but not reported to a physician or provider for several days. No treatment orders or dressing changes were initiated until the wound NP assessed the wound, despite facility policy requiring prompt notification and intervention. Interviews with LPNs and the DON confirmed that the expected notifications and care orders were not completed in a timely manner.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, but staff did not perform a comprehensive wound assessment or initiate treatment orders until several days later. Despite facility policy requiring prompt evaluation and intervention, nursing staff failed to document wound details or contact providers for care, resulting in a lack of timely wound management until a wound NP intervened.
A registered nurse delegated medication administration and blood glucose checks to a CNA, who is not licensed to perform these tasks, resulting in unlicensed staff administering medications and performing clinical procedures. In a separate incident, an LPN failed to verify the resident's name on a medication supply card and prepared medication from the wrong resident's supply. These actions led to a failure to meet professional standards of nursing care.
Staff failed to consistently implement enhanced barrier and contact precautions for residents with indwelling devices or multidrug-resistant infections, including not using required PPE and not posting appropriate signage. Additionally, staff did not perform proper hand hygiene during incontinent care and meal tray delivery, increasing the risk of cross-contamination among residents.
Facility staff did not honor a resident's stated preference for twice-weekly showers, as documented in the admission MDS and scheduled by staff. Despite the resident's medical conditions and moderate cognitive impairment, records showed only one shower was provided, with bed baths given on other scheduled days. The unit manager was unable to provide evidence that the resident received showers as planned.
Staff failed to promptly notify the physician and responsible party of significant changes in condition for two residents, including the onset of a urinary tract infection with new wounds and the dislodgement of a feeding tube. In both cases, documentation and interviews confirmed that required notifications were not made in a timely manner, despite facility policy mandating prompt communication.
A resident with severe cognitive impairment was found with unexplained facial and neck bruising and a skin tear. Facility staff did not immediately report the injury of unknown origin to the state agency or APS as required by policy, and there was no evidence of timely notification to the appropriate authorities.
A resident with severe cognitive impairment and multiple health issues was found with unexplained facial and neck bruising and a skin tear. Facility staff did not immediately report the injury to the state agency or APS as required, and documentation showed delays and inconsistencies in notification. The incident was not reported in accordance with facility policy, and there was no evidence of timely communication with the appropriate authorities.
A resident with multiple complex medical conditions and severely impaired cognition was admitted, and although a baseline care plan was created, there was no documentation that the plan was reviewed with or provided to the resident's representative. Staff confirmed that the baseline care plan should have been shared, but the required documentation and provision of the summary did not occur.
A resident with multiple chronic conditions expressed a preference for female caregivers, which was honored in practice but not documented in the care plan. Staff interviews confirmed that this preference should have been included in the care plan following assessment and review, but it was omitted.
Two residents with severe cognitive impairment and total incontinence did not receive timely incontinence care, with staff failing to check for urine and bowel incontinence at the required intervals. Staff relied on smell rather than visual inspection to detect bowel incontinence, resulting in both residents remaining in soiled briefs for over three hours, contrary to care plan and facility policy expectations.
The facility did not have a certified Activity Director overseeing the activities program for all residents. The Activity Director was not informed of the certification requirement when hired and had not completed the process, although she was enrolled in a certification class and had received course materials. The Administrator confirmed the lack of certification and provided documentation of the director's enrollment.
A resident with a chronic leg ulcer and peripheral vascular disease was found without a required wound dressing, as the dressing had come off during morning care and staff did not promptly replace it or notify the nurse. The wound was left uncovered with drainage, contrary to physician orders for daily wound care and dressing.
A resident with severe cognitive impairment and multiple risk factors for pressure ulcers was not repositioned by staff for several hours, despite care plan interventions and facility policy requiring frequent turning and repositioning. Staff interviews confirmed the lack of repositioning, and leadership acknowledged the expectation for two-hourly repositioning for residents unable to move themselves.
The facility did not maintain safe water temperatures for a resident, failed to follow required transfer protocols for two residents with significant physical and cognitive impairments, and applied a wander guard device to a resident without completing the necessary assessment or obtaining a physician's order.
Failure to Notify Physician and Initiate Treatment Orders for Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the physician or provider regarding an unstageable pressure ulcer identified on a resident upon admission. The resident, who had multiple diagnoses including congestive heart failure, diabetes, and a history of pressure ulcers, was assessed with an unstageable pressure ulcer on the right hip during the admission nursing assessment. Despite documentation of the wound in daily skilled notes and skin assessments, there was no evidence of any treatment orders or dressing changes for the wound until several days later. Clinical record review showed that the pressure ulcer was present and documented, but no notification was made to the physician or provider, and no treatment orders were initiated until the wound nurse practitioner assessed the wound days after admission. Interviews with LPNs and the wound NP confirmed that standard practice required contacting the in-house or on-call provider for treatment orders when a pressure ulcer was identified, but this was not done. The director of nursing also confirmed that there were no documented treatments or dressing changes for the pressure ulcer until the wound NP's assessment. Facility policies required prompt notification of the physician or practitioner for changes in a resident's condition, including new or existing pressure ulcers, and for staff to report changes in skin integrity. Despite these policies, the required notifications and treatment orders were not obtained in a timely manner, resulting in a delay in care for the resident's pressure ulcer.
Failure to Timely Assess and Treat Pressure Ulcer on Admission
Penalty
Summary
Facility staff failed to thoroughly assess and implement timely interventions for the care of a pressure ulcer for one resident. Upon admission, the resident was noted to have an unstageable pressure ulcer on the right hip, but the initial assessment lacked a detailed description of the wound, including its size, appearance, condition of surrounding skin, and presence of drainage, odor, or pain. Daily skilled notes acknowledged the presence of the pressure ulcer but did not document any treatments or dressing changes. No comprehensive assessment or treatment orders were initiated for the pressure ulcer until five days after admission, when a wound nurse practitioner performed a thorough assessment and began appropriate wound care. The resident had multiple comorbidities, including congestive heart failure, atrial fibrillation, diabetes, obesity, and cognitive communication deficit, and was assessed as cognitively intact. Despite the presence of a pressure ulcer on admission and the absence of hospital-provided wound care orders, nursing staff did not contact the in-house provider, on-call provider, or wound nurse practitioner to obtain necessary treatment orders. Interviews with LPNs and the DON confirmed that no comprehensive wound assessment or treatment orders were documented prior to the wound nurse practitioner's intervention, and staff could not explain why appropriate actions were not taken when the wound was first identified. Facility policy required prompt reporting and documentation of changes in skin integrity, comprehensive wound assessments, and timely notification of providers for evaluation and treatment. These procedures were not followed, as evidenced by the lack of detailed wound assessment, absence of treatment orders, and failure to implement dressing changes for the pressure ulcer during the initial days after admission. The deficiency was confirmed through staff interviews, clinical record review, and facility policy review.
Failure to Ensure Nursing Services Met Professional Standards of Quality
Penalty
Summary
Nursing services failed to meet professional standards of quality when a registered nurse (RN) delegated the administration of oral medications and the performance of fingerstick blood glucose checks to a certified nurse aide (CNA), who is not licensed to perform these tasks. The RN pulled medications and allowed the CNA to administer them to multiple residents, and also permitted the CNA to perform blood glucose monitoring. The CNA confirmed administering medications to at least two residents and performing a blood glucose check on another, while the RN acknowledged asking the CNA to perform these tasks. This delegation of duties was outside the CNA's scope of practice and not permitted by facility policy or state regulations. Additionally, during a medication pass observation, a licensed practical nurse (LPN) failed to verify the resident's name on a pharmacy supply card before preparing medication for administration. The LPN obtained torsemide tablets from a supply card labeled for a different resident and prepared to administer them to another resident. The LPN admitted to checking only the medication and dose, not the resident's name, and stated that the supply card had been misplaced in the medication cart. The unit manager confirmed that the LPN did not follow the expected procedure of verifying the correct medication, dose, and resident name. The residents involved had various medical diagnoses, including diabetes mellitus, hypertension, Parkinson's disease, major depressive disorder, atrial fibrillation, chronic pain, and vascular dementia. The facility's own documentation and staff interviews substantiated that unlicensed staff performed tasks restricted to licensed personnel, and that medication administration procedures were not properly followed, resulting in a failure to ensure nursing services met professional standards of quality.
Failure to Implement Infection Control Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as evidenced by multiple observed deficiencies in the use of enhanced barrier precautions (EBP), contact precautions, and standard hand hygiene protocols. For two residents with indwelling medical devices, staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. In one case, a resident with a suprapubic catheter had EBP signage inside the room but lacked PPE availability in the room or bathroom, and there was no external indicator of EBP status. Staff admitted to forgetting to wear gowns and were unclear about the location and use of EBP indicators. Another resident with a feeding tube also did not have appropriate PPE available, and staff were unaware of the resident's EBP status despite signage being present in the room. For a resident being treated for a multidrug-resistant urinary tract infection, the facility did not follow contact precautions protocols. There was no signage on the door to indicate the type of precautions required, and PPE such as gloves, gowns, or masks was not readily available near the room entrance. Staff acknowledged the absence of proper signage and PPE setup, and there was confusion regarding the placement of EBP and contact precaution signage. Additionally, staff failed to perform required hand hygiene during incontinent care and meal tray delivery. During incontinent care, a CNA did not perform hand hygiene after removing gloves and before handling clean linen, only washing hands after disposing of soiled linens. During meal service, the same CNA did not perform hand hygiene between delivering trays to multiple residents, even after touching items in residents' rooms and assisting with feeding. Interviews with staff and review of facility policy confirmed that these actions were not in accordance with expected infection control practices.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
Facility staff failed to honor a resident's expressed preference for twice-weekly showers. The resident, who had diagnoses including a left femur fracture, osteoarthritis, malnutrition, and anxiety, was assessed as moderately cognitively impaired and indicated on the admission MDS that choosing how to bathe was very important. Review of shower records showed the resident only received a shower on one occasion, with subsequent bathing logs indicating bed baths rather than showers on the scheduled days. The unit manager confirmed the resident was scheduled for showers twice weekly but could not provide evidence that these showers were consistently provided as scheduled. This deficiency was presented to facility leadership, and no additional information was provided prior to the exit conference.
Failure to Timely Notify Physician and Representative of Changes in Condition
Penalty
Summary
Facility staff failed to timely notify the physician and the resident or their representative of significant changes in condition for two residents. For one resident with diagnoses including urinary tract infection, urine retention, pressure ulcers, and renal insufficiency, there were multiple documented changes in condition and treatment, such as the onset of a urinary tract infection requiring intravenous antibiotics, the insertion of a PICC line, and the development of unstageable pressure ulcers. Despite these events, there was no documentation that the resident or their responsible party was informed of these changes until several days later, and the responsible party expressed concern about the lack of timely notification. In another case, a resident with severe cognitive impairment and dependent on a feeding tube experienced a dislodgement of the enteral feeding tube. The incident was discovered when the resident was sent out for a neurology appointment, and the family member present at the appointment noticed the absence of the tube and bleeding at the stoma site. Documentation did not show that the family or physician was notified of the dislodgement prior to the resident being sent out for medical attention. Interviews with staff and administration confirmed that the expected notifications did not occur as required. Facility policy requires prompt notification of the resident, physician, and representative of changes in condition, but in both cases, there was a lack of timely communication and documentation regarding significant changes in the residents' medical status. No additional information or evidence of timely notification was provided prior to the survey exit.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to follow abuse prevention policies regarding the immediate reporting of an injury of unknown origin for one resident. The resident, who had multiple diagnoses including dementia with severe cognitive impairment, was found with moderate bruising on both sides of the face and neck, as well as a skin tear on the right cheek. The resident was unable to explain the cause of the injuries due to baseline confusion, and there was no documentation of a recent fall or incident that could account for the injuries. The facility's nursing note indicated that the DON and the resident's emergency contact were notified, but there was no evidence of immediate reporting to the state agency or adult protective services (APS) as required by facility policy. Facility documentation included an initial synopsis form describing the injury, but there was no confirmation that this report was sent to the state agency, APS, or the department of health professions (DHP). The state agency had no record of receiving the initial report, and there were conflicting report dates regarding notification to APS. The administrator and DON confirmed during interviews that there was no evidence of immediate notification to the required authorities, and only the final investigation findings were confirmed as submitted several days after the incident. The facility's policy required immediate reporting of such incidents, but this was not followed in this case.
Failure to Immediately Report Injury of Unknown Origin Suspicious for Abuse
Penalty
Summary
Facility staff failed to immediately report an injury of unknown origin, suspicious for abuse, involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, and depression. The resident was found with moderate bruising on the face and neck, as well as a skin tear, with no documented cause or recent incident to explain the injuries. The nursing note indicated that the resident was unable to communicate what had happened due to baseline confusion, and the Director of Nursing and emergency contact were notified. However, there was no evidence that the injury was immediately reported to the state agency or adult protective services (APS) as required. Facility documentation showed inconsistencies and delays in reporting, with the initial incident form completed but lacking confirmation of submission to the appropriate authorities. The state agency had no record of receiving the initial report, and APS was not notified until several days after the incident. Interviews with the current administrator and DON confirmed the absence of fax or email confirmations and an inability to explain the conflicting report dates. The facility's policy required immediate reporting of such incidents, but this was not followed in this case.
Failure to Provide Baseline Care Plan Summary to Resident's Representative
Penalty
Summary
Facility staff failed to provide a baseline care plan summary to the resident's representative within 48 hours of admission for one resident. The resident was admitted with multiple complex diagnoses, including Parkinson's disease, sepsis, urinary tract infection, pressure ulcer, respiratory failure, and a history of hip fracture, and was assessed as having severely impaired cognitive skills. The admission assessment included a baseline care plan addressing key care areas such as catheter care, constipation prevention, hospice services, diet, pressure ulcer care, fall prevention, and assistance with activities of daily living. Despite the creation of the baseline care plan, there was no documentation in the clinical record that the plan was reviewed with the resident's representative or that a summary or copy of the plan was provided. The relevant sections of the admission assessment regarding completion and review of the baseline care plan, as well as provision of the plan summary and medications, were not completed. Staff interviews confirmed that the baseline care plan should have been reviewed and provided to the family, and that this could be done through the electronic health record, but there was no evidence this occurred.
Failure to Update Care Plan with Resident's Caregiver Preference
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for one resident following the identification of a specific care preference. The resident, who was admitted with multiple diagnoses including spinal stenosis, cardiomyopathy, chronic respiratory failure, diabetes, and depression, was assessed as cognitively intact. During an interview, the resident expressed a preference for female caregivers to provide personal care, a preference that had been honored in practice by the facility. However, a review of the resident's care plan, last revised on 3/28/25, showed that while assistance with activities of daily living was documented, there was no mention of the resident's preference for female caregivers. Interviews with facility staff, including the LPN unit manager and the RN MDS coordinator, confirmed that this preference should have been included in the care plan but was not. The omission was acknowledged by staff during the survey, and no additional information was provided by facility leadership before the survey concluded.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for activities of daily living, specifically incontinence care. Both residents had severe cognitive impairment and were always incontinent of bladder and bowel, as documented in their care plans and Minimum Data Set (MDS) assessments. The care plans for both residents specified that they were not candidates for a toileting program and required staff to provide toileting hygiene as needed for incontinent episodes, with the goal of keeping them clean and dry. Observations revealed that both residents remained in their Broda chairs in the dining room for extended periods without being checked for incontinence. For one resident, there was a gap of three hours between incontinence checks, during which the resident was found to have had a thick and sticky bowel movement. The assigned CNA reported relying on smell to detect bowel incontinence and only visually checked the front of the brief for urine incontinence, without fully inspecting for fecal incontinence. The other resident was also not checked for incontinence for over three hours, with the CNA confirming that she did not open the brief to check for urine or bowel incontinence, again relying on smell for detection of fecal incontinence. Interviews with the CNA, the unit manager RN, and the DON confirmed that the expectation was for residents to be checked for incontinence at least every two hours and that a visual check for both urinary and bowel incontinence was required. The facility's policy also required staff to provide incontinence care as needed. Despite these expectations and policies, staff did not perform timely or thorough incontinence checks for the two residents, resulting in a failure to meet their care needs as outlined in their care plans.
Uncertified Activity Director Led Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a certified Activity Director for all 114 residents. During interviews, the Activity Director confirmed she was not certified and stated she was unaware of the certification requirement when she accepted the position two years prior. She reported that previous administrators had not discussed the need for certification, but the current administrator had informed her of the requirement and encouraged her to obtain certification. The Activity Director indicated she had enrolled in the necessary class, received the course materials, and completed the required essay, but had not yet submitted it. The Administrator confirmed that the Activity Director was not certified but had been enrolled in the certification class. Documentation of the enrollment was provided. A review of the job description for the Activities Director indicated that appropriate training and/or certification was highly advantageous, but did not specify it as a strict requirement. No further information was provided prior to the survey exit.
Failure to Maintain Wound Dressing as Ordered
Penalty
Summary
Facility staff failed to ensure that a wound dressing was intact for a resident with a non-pressure chronic ulcer on the left calf, adult failure to thrive, and peripheral vascular disease. The resident, who was cognitively intact, was observed without a wound dressing in place and with scant drainage present. The resident reported that the dressing came off during morning assistance with dressing by aides. The registered nurse confirmed the wound was open to air and not covered, and stated that she had not been informed about the missing dressing, despite physician orders requiring the wound to be cleaned and covered with boarded gauze every day shift.
Failure to Reposition High-Risk Resident to Prevent Pressure Ulcers
Penalty
Summary
Staff failed to implement required interventions to prevent pressure ulcers for one resident who was at high risk due to multiple medical conditions, including vascular dementia, failure to thrive, impaired healing from peripheral vascular disease, and protein calorie malnutrition. The resident was severely cognitively impaired, dependent on staff for transfers and repositioning, and had a care plan specifying frequent turning, repositioning, and keeping the skin clean and dry. Despite these documented interventions, the resident was observed sitting in a Broda chair for extended periods without being repositioned by staff. Observations showed that the resident remained in the same position in the Broda chair for several hours, with no staff assistance in repositioning during that time. Interviews with the assigned CNA confirmed that the resident was not repositioned throughout the observed period. The unit manager and DON both stated that the expectation was for staff to reposition residents who are unable to do so themselves at least every two hours. The failure to follow these interventions placed the resident at increased risk for developing pressure ulcers.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for three residents. In one instance, a resident's bathroom sink water temperature was measured at 121.3°F, exceeding the facility's stated safe range of 110°F to less than 120°F. The resident, who was cognitively intact and had multiple medical diagnoses, reported that the water felt very hot but had not experienced any injury. The maintenance director confirmed the temperature was above the required limit and acknowledged the need for seasonal adjustments to maintain safe water temperatures. Documentation showed that previous checks in the same room had recorded temperatures within the acceptable range. In another case, staff failed to follow the required transfer protocol for a resident with severe cognitive impairment and significant physical limitations. The resident's care plan and Kardex specified that all transfers should be performed using a Hoyer lift with two staff members. However, observations revealed that staff transferred the resident manually, without the lift, and at one point, a single staff member completed the transfer alone after another was unable to assist. Both CNAs involved stated they had never used the Hoyer lift for this resident, despite the care plan instructions. The DON confirmed that the care plan and Kardex should accurately reflect the required transfer method and that not following it could result in injury. Additionally, the facility failed to complete a required assessment and obtain a physician's order before applying a wander guard device to a resident at risk for elopement. The resident, who had severe cognitive impairment and a history of wandering, was observed wearing a wander guard without a current elopement risk assessment or a physician's order documented in the medical record. The DON acknowledged that both an assessment and a physician's order were required for the use of such a device, and facility policy supported this requirement.
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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 | 3.4 mi | ★★★★★ | 5 | 0 |
| Liberty Ridge Health & Rehab | 3.8 mi | ★★★★★ | 0 | 0 |
| Seven Hills Rehabilitation And Nursing | 5.2 mi | ★★★★★ | 8 | 1 |
| Tate Springs Health & Rehab | 5.3 mi | ★★★★★ | 0 | 0 |
| Forest Health & Rehab Center | 5.4 mi | ★★★★★ | 1 | 0 |
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