Westminster-Canterbury of Lynchburg Inc

In the surveyor’s words

From the most serious findings on record at Westminster-Canterbury of Lynchburg Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF758May 5, 2021

  Based on clinical record review and staff interview, the facility staff failed to ensure a pharmacy GDR [gradual dose reduction] recommendation was completed for one of 20 residents [Resident #8]. Resident #8's physician signed a GDR pharmacy recommendation for [MEDICATION(S)] [a hypnotic medication for sleep] to be decreased from 2 mg [milligrams] to 1 mg nightly; however, Resident #8 continued to received 2 mg nightly for over 5 months. Findings include: Resident #8 was admitted to the facility on [DATE]. Diagnoses for Resident #8 included, but were not limited to: [CONDITION(S)], Alzheimer's dementia, restless leg syndrome, anxiety disorder, and [CONDITION(S)]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. […]

• No harm, potential for more than minimal, isolatedF641Mar 19, 2026

  Based on staff interview and clinical record review the facility staff failed to ensure an accurate MDS assessment for 1 of 25 residents, Resident #2. The findings included:For Resident #2, the facility staff coded an admission MDS assessment to indicate the resident was taking an antibiotic at the time of the assessment. Resident #2 had not been on an antibiotic.Resident #2's diagnoses included genital tract fistulae and anxiety disorder.Section C (cognitive patterns) of Resident #2's admission MDS assessment with an assessment reference date (ARD) of 01/15/26 included a brief interview for mental status (BIMS) score of 15, indicating Resident #2 was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF684Mar 19, 2026

  Based on observations, staff interview, clinical record review and facility document review the facility staff failed to follow medical provider orders for 2 of 25 residents, Resident #5 and Resident #8. The findings included:1. For Resident #5, the facility staff failed to follow a medical provider orders to apply TED hose (Thrombo-Embolic Deterrent hose are specialized medical compression stockings designed to prevent blood clots) to the resident's BLE (bilateral lower extremities) on 3/18/26. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's disease, osteoarthritis, lymphedema, and edema. […]

• No harm, potential for more than minimal, isolatedF641Feb 8, 2023

  Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty residents in the survey sample (Resident #56). The findings include: Section L. of Resident #56's annual MDS dated [DATE] assessed the resident with no dental impairments when the resident had multiple broken teeth with likely decay. Resident #56 was admitted to the facility with diagnoses that included hypertension, glaucoma, heart failure, anemia, obstructive sleep apnea, epilepsy, vitamin D deficiency and atrial flutter. The MDS dated [DATE] assessed Resident #56 with moderately impaired cognitive skills. On 2/6/23 at 3:15 p.m., Resident #56 was interviewed about quality of life and care in the facility. […]

• No harm, potential for more than minimal, isolatedF684Feb 8, 2023

  Based on medication pass and pour observation, staff interview, and clinical record review the facility staff failed to follow physician's orders for Resident # 58. Findings include: A medication pass and pour observation was conducted 2/7/23 beginning at 8:20 a.m. with LPN (licensed practical nurse) # 1. LPN # 1 prepared medications for Resident # 58, which included acetaminophen (Tylenol) 325 mg, two tablets. On 2/7/23 at approximately 9:05 a.m. the clinical record was reviewed to reconcile medications observed having been administered to the resident. […]