Seven Hills Rehabilitation And Nursing
SEVEN HILLS REHABILITATION AND NURSING in LYNCHBURG, VA — inspection on April 30, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the review, the training on CNA3's transcript had that her training on Cultural Competence Inservice, Abuse, Neglect, and Exploitation, and Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees were overdue.
The training was assigned on February 2, 2026, and was to be completed by the employee on February 28, 2026.On 4/30/26 at 9:00 am, The administrator provided the employee records to be reviewed and stated, this was the yearly training records for the employees.
The administrator stated the employees were required to complete these training courses yearly and by the due date.On 4/30/26 a review of the facility policy titled, Abuse, Neglect, and Exploitation, read in part, Employee Training A.
New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B.
Existing staff will receive annual education through planned in-services and as needed.
Training topics will include: C. 1.
Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. 2.
Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 3.
Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. 4.
Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources. 5.
Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a.
Aggressive and/or catastrophic reactions of residents. b.
Wandering or elopement-type behaviors. c.
Resistance to care. d.
Outbursts or yelling out; and e.
Difficulty in adjusting to new routines or staff.On 4/30/26 at approximately 10:30 am, a meeting was held with the director of nursing (DON), the administrator, and the regional director of clinical services.
During the meeting the DON stated she was a new hire, and the training should have been completed. No additional information was provided.No additional information was provided prior to exit conference Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
Resident # 1 was discharged from facility2. -reviewed the audit performed of facility reported
jeopardy to resident health or family interviews for residents with a BIMS below 12 -reviewed interviews for residents with a BIMS safety of 12 or above3.
Interviewed staff for education regarding the abuse policy and procedures to follow.
The IJ was determined to have been removed as of 12:00 am on 4/30/26, at which time the scope and
Exploitation, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 2.
The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or law. suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state 3.
The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.On 4/30/26 at10:35 am, the vice president of clinical services and the administrator was wanting to discuss their creditable evidence, dispute of Immediate Jeopardy Determination that they had presented earlier.
The information provided was reviewed and it did not provide credible evidence that residents were protected from an alleged perpetrator during an abuse allegation.No additional information was provided prior to exit conference.
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
right to refuse treatment.
The policy further states The comprehensive care plan will be reviewed and
presented to the Director of Nursing (DON) and administrator.No further information was provided
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
During the review there was a pharmacy label that read Divalproex DR 500mg.
Take two in the morning and three at bedtime.
The action plan the facility presented was as follows: Quality Assurance Committee oversight.Medication cards were removed from the medication cartsMedication ordered with correct dosePharmacy was notified of error. NP [nurse practitioner] reviewed that orders and clarified that Divalproex DR should be sent for 250mgA MAR [medication administration record] to card audit was completedMedication administration education given to nursing staffNew medication cards sent for this resident were checked for accuracyThe completion date was 6/23/25 and the audits being conducted were MAR to card audit was completed on 8/25/25.
The completion audit for accuracy of medication cards dispensed from the pharmacy was completed on 9/2025.
The facility achived past non-compliance for this deficient practice. No other additional information was provided prior to exit conference.
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
for increased, uncontrolled pain with a reported pain score of 10/10.
Staff were called to the
noted chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular
review, with pain reported as partially controlled throughout subsequent progress notes.
The resident continued to report episodes of uncontrolled pain, with pain ratings up to 10/10, and analgesic dosages were adjusted according.
However, there was no evidence of non-pharmacological interventions or other alternative pain management approaches being implemented or documented to assist in alleviating the resident's pain. On 4/29/26 a review was conducted of facility documentation that was provided.
The policy titled, Pain Management, was reviewed and read in part, .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. 1. c. manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. On 4/30/26 at 10:00 am, a meeting was held with the administrator, the director of nursing, and the regional nurse of clinical services and the above findings were discussed. No additional information was obtained prior to exit conference.
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
following irregularity reporting guidelines in developed policies and procedures.
failed to ensure that pharmacy regimen reviews were completed and implemented timely for one
pharmacy regimen reviews were not completed or implemented timely.On 4/30/26 at 8:45 am, an interview was conducted with the director of nursing (DON).
The DON explained the facility process of the drug regimen reviews.
The DON stated that the coordinator from the pharmacy will let me know when she is coming and when reviews were ready .
She stated that she will review and give to the doctor to review and sign.
Once signed by the physician, the DON stated she gives the reviews to the unit managers to check and to make sure the suggestions was implemented.
The DON said she makes a copy of all the reviews, place copies in a binder, and it was kept in her office.
She stated she takes the original review to the medical records department and the review was scanned into the residents medical chart. On 4/30/26. a review of R1's clinical recorded was conducted. R1's pharmacy consultations were reviewed. R1 had a review that was completed on 2/18/2025 for a gradual dose reduction of his antipsychotic medication Quetiapine 100 mg was reduced to 75 mg, and this recommendation was not reviewed and completed until 3/25/25 with the physician's signature. On 2/18/26 a recommendation was completed for a current AIMS and this recommendation was not signed and completed until 3/27/25. On 7/29/25 a recommendation was requested for a gradual dose reduction for R1's antidepressant (Duloxetine 60 mg twice daily); however, this recommendation was not addressed until 9/5/25 by the physician. On 11/26/25 a recommendation for a dose reduction was made on R1's pantoprazole 40 mg everyday to 20 mg; however, the recommendation was not reviewed and signed by the physician until 12/24/25. On 4/30/26, a review of the facility policy was reviewed.
The policy titled, Medication Regimen Review, read in part, .the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. On 4/30/26 at 10:00 am, a meeting was held with the administrator, the director of nursing, and the regional director of clinical services and were made aware of the above concerns. No additional information was obtained prior to exit conference.
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
During the review there was a pharmacy label that read Divalproex DR 500mg.
Take two in the morning and three at bedtime.
The action plan the facility presented was as follows: Quality Assurance Committee oversight.Medication cards were removed from the medication cartsMedication ordered with correct dosePharmacy was notified of error. NP [nurse practitioner] reviewed that orders and clarified that Divalproex DR should be sent for 250mgA MAR [medication administration record] to card audit was completedMedication administration education given to nursing staffNew medication cards sent for this resident were checked for accuracyThe completion date was 6/23/25 and the audits being conducted were MAR to card audit was completed on 8/25/25.
The completion audit for accuracy of medication cards dispensed from the pharmacy was completed on 9/2025.
The facility achived past non-compliance for this deficient practice. No other additional information was provided prior to exit conference.
Past non-compliance was achieved.
495151 04/30/2026
Seven Hills Rehabilitation and Nursing 2081 Langhorne Road Lynchburg, VA 24501
During the interview, the administrator confirmed she was the Abuse Coordinator.
She stated that when an allegation of abuse was made, she reported it immediately to the required state agencies, initiated an investigation, and removal and suspension of the alleged perpetrator from the facility pending the outcome of the investigation.
The administrator confirmed this was the facility's policy for abuse allegations.Facility documentation confirmed that both perpetrators were allowed to remain in the facility and continued to work their schedules during the investigations. CNA1 was involved in the incident on 5/30/25 and her timecard revealed that she completed her shift on 5/29/25, the day the incident happened and was allowed to work on 5/30/25 and clocked in at the facility on 5/31/25 at 11:37 pm to 11:44 pm. CNA2 was involved in the second incident with R1 on 10/30/25. CNA2's timecard revealed that she completed her schedule shift on 10/30/25, worked her schedule shift on 10/31/25, 11/3/25, and on 11/4/25.R1 also made an allegation of verbal abuse which was not investigated by the facility. On 4/28/26 a review of the facility policy titled, Abuse, Neglect, and Exploitation, and read in part, 2.
The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or law. suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state
- The facility will provide ongoing oversight and supervision of staff in order to assure that its
policies are implemented as written.Failure to remove the perpetrators, by the abuse coordinator during the investigations did not ensure the safety and protection of Resident #1 and other residents from potential abuse.On 4/28/25 an end of day meeting was conducted with the administrator, the director of nursing and the regional nursing consultant. No additional information was provided prior to exit
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.