Inspection Reports for
The Elms of Lynchburg LLC
2249 Murrel Road, LYNCHBURG, VA, 24501
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Inspection Reports Summary
Covers 16 inspections · Aug 2025 – Jun 2026Visit Reason
This report covers 16 inspections of The Elms of Lynchburg LLC from August 27, 2025 to June 16, 2026, including complaint and routine inspections with areas reviewed, comments, violations, and plans of correction.
Complaint Details
Eight inspections were prompted by complaints alleging non-compliance in areas such as resident care and related services, buildings and grounds, personnel, and additional requirements for facilities caring for adults with serious cognitive impairments. Investigations included resident and staff interviews, record reviews, and physical plant tours. Some complaints were substantiated with violations issued; others were not supported by evidence.
Findings
Across that history VDSS cited 21 violations under 11 distinct standards. 9 of 16 visits ended with violations and 7 with none. 8 inspections were prompted by a complaint.
Violations (21)
22VAC40-73-680-I: MARs lacked staff initials documenting medication administration for multiple residents and dates.
22VAC40-73-680-D: Medications were administered not in accordance with physician orders, including discontinued meds given.
22VAC40-73-680-E: Medical procedures and treatments were not provided or documented as ordered by physicians.
22VAC40-73-40-B: Criminal history record report was not obtained within 30 days of employment for an employee.
22VAC40-73-720-A: DNR orders were not included in the individualized service plan as required.
22VAC40-73-440-D: Uniform assessment instrument (UAI) lacked required documentation of assistance levels.
22VAC40-73-450-D: Hospice care and licensed hospice organization communication and ISP documentation were lacking.
22VAC40-73-250-D: TB risk assessment documentation was incomplete or undated for an employee.
22VAC40-73-640-A: Medication management plan failed to prevent use of outdated, damaged, or contaminated meds.
22VAC40-73-680-E: Blood sugar monitoring was not documented as ordered for multiple residents.
22VAC40-73-680-D: Medications were administered contrary to physician orders, including discontinued meds given.
22VAC40-73-680-I: MARs lacked staff initials documenting medication administration for numerous residents and dates.
22VAC40-73-460-D: Failed to supervise resident schedules, care, and activities including fall and wandering prevention.
22VAC40-73-440-D: UAI did not specify which cognitive spheres were affected for a disoriented resident.
22VAC40-90-40-D: Employee with a felony barrier crime conviction was employed contrary to requirements.
22VAC40-73-680-I: MAR lacked required components including staff initials for medication administration.
22VAC40-73-640-A: Failed to implement medication management plan regarding communication of medication issues.
22VAC40-73-680-D: Medications administered not in accordance with physician orders, including discontinued meds.
22VAC40-73-680-E: Blood sugar checks were not documented as ordered for a resident.
22VAC40-73-680-D: Medications administered not in accordance with physician orders including PRN misuse.
22VAC40-73-680-I: MAR lacked staff initials and documentation of medication administration and effectiveness.
Report Facts
Violations cited: 21
Distinct standards: 11
Inspections on page: 16
Inspections with violations: 9
Complaint visits: 8
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