Inspection Reports for
The Summit
1400 Enterprise Dr, Lynchburg, VA 24502, United States, VA, 24502
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
84% occupied
Based on a March 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician/provider and failure to provide timely treatment orders for a pressure ulcer for Resident #1.
Complaint Details
The complaint investigation found substantiated failure to notify the physician/provider and failure to provide timely treatment for Resident #1's pressure ulcer.
Findings
The facility staff failed to notify the physician/provider of an assessed unstageable pressure ulcer on Resident #1 and did not initiate treatment orders until six days after admission. Documentation and assessments were incomplete, and nursing staff did not follow facility policy for timely notification and treatment.
Deficiencies (2)
F 0580: Facility staff failed to notify the physician/provider of an assessed unstageable pressure ulcer on Resident #1 and did not obtain treatment orders until 5/22/25, six days after admission.
F 0686: Facility staff failed to thoroughly assess and implement timely interventions for care of Resident #1's unstageable pressure ulcer, with no treatment orders or dressing changes documented until 5/22/25.
Report Facts
Residents in survey sample: 5
Pressure ulcer size: 10
Pressure ulcer size: 3.5
Days delay in treatment orders: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse Unit Manager | Interviewed about notification and treatment orders for Resident #1's pressure ulcer. |
| LPN #2 | Licensed Practical Nurse | Interviewed about notification and treatment orders for Resident #1's pressure ulcer. |
| Wound NP | Consultant Wound Nurse Practitioner | Assessed Resident #1's pressure ulcer on 5/22/25 and entered treatment orders. |
| DON | Director of Nursing | Interviewed about lack of physician notification and treatment for Resident #1's pressure ulcer. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-07 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related to resident care and related services; the allegations were not substantiated based on the investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 1
Inspection Report
Monitoring
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 13, 2025, following a self-reported incident received by VDSS Division of Licensing on April 10, 2025, regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Routine
Deficiencies: 12
Date: May 1, 2025
Visit Reason
Routine state inspection survey of Summit Health and Rehab Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to honor resident preferences, failure to notify physicians and families timely of changes in condition, failure to follow abuse reporting policies, failure to provide baseline care plan summaries, failure to update care plans, medication administration errors, failure to provide timely incontinence care, failure to prevent pressure ulcers, environmental safety hazards, failure to have a certified activity director, failure to maintain wound dressings, failure to implement infection control precautions, and failure to perform proper hand hygiene.
Deficiencies (12)
F 0558: Facility failed to honor a resident's preference for twice weekly showers as documented in the care plan and bathing logs.
F 0580: Facility failed to notify physician and responsible party timely of dislodgement of enteral feeding tube for one resident and failed to notify resident or representative timely of change in condition for another resident.
F 0607: Facility failed to immediately report an injury of unknown origin suspicious of abuse to the state agency and adult protective services.
F 0655: Facility failed to provide baseline care plan summary to resident's representative upon admission.
F 0657: Facility failed to review and revise the comprehensive care plan to include resident's preference for female caregivers.
F 0658: Facility failed to ensure licensed nursing services met professional standards by allowing unlicensed staff to administer medications and perform blood glucose checks.
F 0677: Facility failed to provide timely incontinent care for two residents, increasing risk of urinary tract infections and skin breakdown.
F 0680: Facility failed to have safe water temperature below 120°F in a resident's bathroom sink and failed to provide adequate supervision during resident transfer.
F 0684: Facility failed to ensure a wound dressing was intact for one resident as ordered by physician.
F 0686: Facility failed to implement pressure ulcer prevention interventions by not repositioning a high-risk resident every two hours as required.
F 0689: Facility failed to provide safe water temperature, failed to supervise resident transfers per care plan, and failed to complete required elopement risk assessments and orders before applying a wander guard.
F 0880: Facility failed to implement enhanced barrier precautions for residents on infection precautions, failed to post required signage and provide PPE, and failed to perform required hand hygiene during incontinent care and meal service, increasing risk of infection transmission.
Report Facts
Residents in survey sample: 30
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 5
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 3
Residents affected by deficiencies: 114
Residents affected by deficiencies: 7
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN9 | Registered Nurse | Delegated medication administration and blood glucose checks to CNA10 |
| CNA10 | Certified Nurse Aide | Administered medications and performed blood glucose checks outside scope of practice |
| LPN4 | Licensed Practical Nurse, Unit Manager | Provided shower schedule and reviewed bathing logs for Resident #112 |
| LPN2 | Licensed Practical Nurse | Interviewed regarding notification of family for Resident #109 |
| RN7 | Registered Nurse, MDS Coordinator | Responsible for care plan updates, failed to add female caregiver preference for Resident #91 |
| LPN7 | Licensed Practical Nurse | Administered medication to Resident #84 from wrong pharmacy supply card |
| CNA1 | Certified Nurse Aide | Observed failing to perform hand hygiene during incontinent care and meal service |
| RN1 | Registered Nurse | Failed to wear gown during enhanced barrier precautions care for Resident #63 |
| LPN3 | Licensed Practical Nurse | Failed to wear gown during suprapubic catheter care for Resident #86 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies and facility policies |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 1, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to honor resident preferences, failure to notify physicians and families of changes in condition, medication administration errors, delegation violations, inadequate incontinent care, pressure ulcer prevention, infection control breaches, and lack of certified activity director.
Complaint Details
The investigation was complaint-driven, focusing on multiple allegations including failure to honor resident preferences, failure to notify physicians and families of changes in condition, medication errors, delegation violations, inadequate incontinent care, pressure ulcer prevention, infection control breaches, and lack of certified activity director. The findings substantiated these complaints with minimal harm or potential for actual harm to residents.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, failure to timely notify physicians and families of changes in condition, medication administration errors including delegation of nursing tasks to unlicensed staff, failure to provide timely incontinent care and pressure ulcer prevention, failure to implement enhanced barrier precautions and contact precautions properly, and failure to perform required hand hygiene during incontinent care and meal service. The facility also lacked a certified activity director.
Deficiencies (7)
F 0558: The facility failed to honor a preference for twice weekly showers for one of thirty residents (Resident #112).
F 0580: The facility failed to notify the physician and responsible party timely of the dislodgement of a feeding tube for Resident #110 and failed to notify Resident #109 or representative timely of changes in condition.
F 0658: The facility failed to ensure licensed nursing services met professional standards for five residents, including delegation of medication administration to unlicensed staff.
F 0677: The facility failed to provide timely incontinent care for two residents (R36 and R41), placing them at risk for urinary tract infections and skin breakdown.
F 0680: The facility failed to have a certified Activity Director to direct the provision of activities for 114 residents as required.
F 0686: The facility failed to implement interventions to prevent pressure ulcers for one resident (R36) at high risk for pressure ulcers.
F 0880: The facility failed to implement enhanced barrier precautions for two residents (R86 and R63), failed to post contact precaution signage and provide PPE for one resident (R7), failed to perform hand hygiene during incontinent care and linen handling for one resident (R36), and failed to perform hand hygiene during meal service for seven residents, increasing risk of infection.
Report Facts
Residents in survey sample: 30
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 114
Residents affected: 1
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN9 | Registered Nurse | Named in delegation of medication administration to CNA |
| CNA10 | Certified Nurse Aide | Named in delegation of medication administration and blood sugar checks |
| LPN4 | Licensed Practical Nurse, Unit Manager | Provided shower schedule and bathing logs for Resident #112 |
| LPN2 | Licensed Practical Nurse | Interviewed regarding family notification for Resident #109 |
| CNA1 | Certified Nurse Aide | Observed failing to perform hand hygiene during incontinent care and meal service |
| RN4 | Registered Nurse, Unit Manager | Interviewed about incontinent care and hand hygiene expectations |
| LPN7 | Licensed Practical Nurse | Observed medication pass error with wrong resident's medication card |
| LPN3 | Licensed Practical Nurse | Observed providing suprapubic catheter care without gown |
| OS4 | Activity Director | Not certified but enrolled in certification class |
| DON | Director of Nursing | Interviewed regarding multiple findings and facility policies |
| Administrator | Facility Administrator | Interviewed regarding multiple findings and facility policies |
Inspection Report
Monitoring
Census: 42
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and regulations at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed resident and staff records, conducted interviews, and observed meals and medication administration.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Renewal
Census: 42
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance related to the facility's medication management plan, specifically the failure to ensure proper dating and disposal of opened medications such as eye drops.
Deficiencies (1)
Failure to implement medication management plan regarding methods to prevent the use of outdated, damaged, or contaminated medications, specifically undated opened eye drops.
Report Facts
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify a resident's power of attorney of a change in condition and failure to follow professional nursing standards including medication administration errors.
Complaint Details
The complaint investigation found substantiated failures in notifying the power of attorney of a resident's change in condition and multiple medication administration errors affecting several residents.
Findings
The facility failed to notify the power of attorney of a resident's change in condition and failed to administer medications as ordered for multiple residents. The facility also failed to provide pharmaceutical services to meet residents' needs and ensure residents were free from significant medication errors.
Deficiencies (4)
F 0580: Facility staff failed to notify the power of attorney of a change in condition for Resident #11 during a hospital transfer.
F 0658: Facility staff failed to administer medications as ordered and failed to notify physicians for 7 residents, including missed doses and lack of documentation.
F 0755: Facility staff failed to provide pharmaceutical services to meet the needs of 4 residents, including delays and unavailability of medications from pharmacy.
F 0760: Facility staff failed to ensure residents were free from significant medication errors, including omissions of insulin, anti-cancer drugs, antibiotics, and anticoagulants for 5 residents.
Report Facts
Residents in survey sample: 11
Residents affected by medication administration failures: 7
Residents affected by pharmaceutical service failures: 4
Residents affected by medication errors: 5
Inspection Report
Monitoring
Deficiencies: 0
Date: May 4, 2023
Visit Reason
The inspection was a monitoring visit conducted to review administration and resident care services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws during the visit.
Inspection Report
Renewal
Census: 40
Deficiencies: 3
Date: Mar 20, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection found non-compliance with infection control policies related to assisted blood glucose monitoring, medication administration practices inconsistent with standards, and failure to have properly labeled and available PRN medications. Plans of correction were submitted addressing these deficiencies.
Deficiencies (3)
Failure to ensure implementation of infection control policy regarding assisted blood glucose monitoring, including unlabeled glucometer.
Failure to ensure medications were administered consistent with standards of practice; pills left unattended in resident's room.
Failure to ensure PRN medications were available, properly labeled, and properly stored; missing Mucinex medication.
Report Facts
Residents present: 40
Resident records reviewed: 8
Resident records reviewed for medication administration: 2
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the inspection |
| Staff 2 | Registered Medication Aide | Named in medication administration deficiency for leaving pills unattended |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 18
Date: Apr 21, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Summit Health and Rehab Center.
Findings
The facility was found deficient in multiple areas including medication administration errors, failure to notify physicians of unavailable medications, incomplete care plans, failure to provide Medicare non-coverage notices, inadequate infection control practices, and dietary service deficiencies. Several residents did not receive medications as ordered due to pharmacy supply issues and communication failures.
Deficiencies (18)
F554: Facility failed to evaluate Resident #8 for self-administration of medications as clinically appropriate.
F580: Facility failed to notify physicians promptly about unavailable medications for Residents #230, #59, and #15.
F582: Facility failed to provide Medicare notice of non-coverage to Residents #18, #128, and #130 prior to last day of Part A service.
F622: Facility failed to document hospital discharge for Resident #12 adequately.
F635: Facility failed to ensure physician orders for central line catheter care for Resident #230 upon admission.
F655: Facility failed to develop a baseline care plan for central venous access catheter for Resident #230.
F656: Facility failed to develop comprehensive care plans for Residents #15, #28, and #13 addressing impacted ear wax, antidepressant use, and nutritional needs respectively.
F658: Facility failed to meet professional standards of quality in medication administration for Residents #15, #23, and #230, including medication errors and incorrect injection site.
F684: Facility failed to administer medications as ordered for Residents #230, #59, #15, #46, and #14, and failed to complete glucometer calibration monitoring on three nursing units.
F697: Facility failed to provide appropriate pain management for Resident #14 by not administering scheduled Lidocaine 4% patches for 4 consecutive days.
F744: Facility failed to develop a dementia-specific care plan for Resident #13 with dementia diagnosis.
F755: Facility failed to provide pharmaceutical services ensuring availability of medications for Residents #15, #46, #59, #14, and #230.
F760: Facility failed to ensure Residents #230 and #59 were free from significant medication errors related to missed IV antibiotics and bowel regimen medications.
F761: Facility failed to ensure medications and biologicals were properly dated when opened and removed expired medications on multiple units.
F803: Facility failed to offer alternate menu entrée items prepared in advance and compatible with other menu items; residents reported dissatisfaction with food choices and quality. Census was 79 residents.
F808: Facility failed to have a physician's order for a therapeutic diet for Resident #13 upon readmission.
F849: Facility failed to ensure hospice provider submitted weekly hospice visit records for Resident #35 as required by agreement.
F880: Facility failed to implement infection control protocols for Resident #75 on contact precautions and failed to conduct Legionella testing since 2019.
Report Facts
Residents in survey sample: 21
Census: 79
Days IV Vancomycin not administered: 4
Days Dulcolax not administered: 9
Days Sodium Chloride not administered: 6
Missed Lidocaine patch doses: 4
Cognitive score Resident #8: 11
Cognitive score Resident #13: 3
Cognitive score Resident #15: Cognitively intact (exact score not stated)
Cognitive score Resident #46: 14
Cognitive score Resident #59: 14
Cognitive score Resident #14: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Cared for Resident #15; interviewed about medication errors and unavailable medications |
| RN #1 | Registered Nurse Unit Manager | Interviewed about medication administration issues and care plans |
| DON | Director of Nursing | Interviewed regarding medication availability, policies, and deficiencies |
| ADON | Assistant Director of Nursing | Interviewed regarding medication availability and facility issues |
| RN #2 | Registered Nurse Unit Manager | Provided care for Resident #28 and Resident #13; interviewed about care plans |
| RN #3 | Assistant Director of Nursing | Interviewed about medication errors and care plans |
| RN #5 | Registered Nurse Unit Manager | Interviewed about medication administration and infection control |
| LPN #3 | Licensed Practical Nurse | Provided care for Resident #14 and Resident #13; interviewed about missed doses and behaviors |
| Pharmacy Director of Quality | Pharmacy Director | Interviewed about medication availability and pharmacy issues |
| OS #2 | Dietary Manager | Interviewed about dietary concerns and menu alternatives |
| OS #4 | Nurse Practitioner | Interviewed about medication errors and hospice care |
| CNA #1 | Certified Nurses' Aide | Observed and interviewed regarding infection control breach |
Inspection Report
Renewal
Census: 41
Deficiencies: 0
Date: Mar 3, 2022
Visit Reason
The visit was an unannounced mandated renewal inspection conducted to assess compliance with the Standards for Assisted Living Facilities.
Findings
The inspection included a tour of the physical plant, observation of medication passes, review of medication storage carts, resident interviews, and staff record reviews. No violations were cited during the renewal inspection.
Inspection Report
Monitoring
Census: 41
Deficiencies: 1
Date: Dec 8, 2021
Visit Reason
An unannounced mandated monitoring inspection was conducted to assess compliance with the Standards for Assisted Living Facilities, including review of resident records, medication passes, staff records, and facility documentation.
Findings
The facility failed to ensure that the Individualized Service Plan (ISP) addressed all identified needs for some residents, specifically missing oxygen flow rate details and lacking written descriptions of physical therapy services and providers in ISPs for certain residents.
Deficiencies (1)
The facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs, including missing oxygen flow rate and incomplete descriptions of physical therapy services.
Report Facts
Residents in care: 41
Inspection Report
Original Licensing
Census: 45
Deficiencies: 0
Date: Sep 13, 2021
Visit Reason
An announced mandated initial on-site inspection was conducted to evaluate compliance with applicable standards and laws for licensing purposes.
Findings
The inspection included a tour of the physical plant and review of policies and procedures. No violations were found and all required components and documentation were complete.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 24, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for Summit Health and Rehab Center.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders for immediate care devices, failure to develop baseline and comprehensive care plans for residents, conflicting and incomplete assessments regarding bed rail use without informed consent, and failure to ensure appropriate use and documentation of psychotropic medications.
Deficiencies (6)
F 0635: Facility staff failed to obtain physician orders for the immediate care of a wound vac for one of 22 residents, Resident #89.
F 0655: Facility staff failed to develop a baseline care plan for two of 21 residents admitted with wound vac devices.
F 0656: Facility staff failed to develop and implement a complete care plan that meets all the resident's needs for Resident #85 and Resident #62.
F 0657: Facility staff failed to review and revise a comprehensive care plan for Resident #86 after discontinuation of IV antibiotics and PICC line.
F 0700: Facility staff failed to accurately assess, obtain informed consents, and attempt alternatives prior to the use of bed rails for Residents #11 and #62.
F 0758: Facility staff failed to ensure Resident #62 was free from unnecessary medication with a prn Lorazepam order in place over 14 days without documented rationale or specified duration.
Report Facts
Residents in survey sample: 22
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Unit Manager | Interviewed regarding wound vac care and care plan for Resident #89. |
| RN #2 | Registered Nurse | Interviewed regarding wound vac and contact precautions for Resident #85. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding bed rails and mitten use for Residents #62 and #11. |
| DON | Director of Nursing | Interviewed regarding care plans, bed rails, and medication orders. |
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