Inspection Reports for
Lakeside ALF Operations, LLC
2125 Hilliard Road, HENRICO, VA, 23228
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
17 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Census: 17
Deficiencies: 1
Date: Jun 4, 2025
Visit Reason
An on-site renewal inspection was conducted to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws except for one deficiency related to the individual service plan not being signed and dated by the licensee or resident/legal representative. The deficiency was corrected during the inspection.
Deficiencies (1)
The facility did not ensure that individual service plan for each resident was signed and dated by the licensee, administrator, or their designee, and by the resident or their legal representative.
Report Facts
Number of residents present: 17
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff #2 | Confirmed missing signatures on resident's service plan |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-08-05 regarding allegations related to resident care and physical conditions of the facility.
Complaint Details
A complaint/self-reported incident was received by VDSS Division of Licensing on 08/05/2024 regarding allegations in the areas of resident care and physical conditions of the facility. The evidence gathered did not support the allegations, and the complainant was provided with contact information for the responsible oversight agency.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The alleged violations were not occurring in the assisted living portion of the facility.
Inspection Report
Renewal
Census: 1
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to review compliance with applicable standards and licensing requirements.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, and observations of resident care. No violations of applicable standards or laws were found during the inspection.
Report Facts
Residents present: 1
Resident records reviewed: 1
Staff records reviewed: 3
Resident interviews conducted: 1
Staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Date: Mar 4, 2024
Visit Reason
The inspection was conducted in response to a complaint received on November 8, 2023, regarding allegations related to medication/medical issues and housekeeping/sanitation at the assisted living facility.
Complaint Details
Complaint was received by VDSS Division of Licensing on November 8, 2023, regarding medication/medical issues and housekeeping/sanitation. The evidence gathered did not support the allegations.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or laws. The inspection included a tour of the facility and observations of medication pass, storage, resident rooms, dining, and common areas.
Report Facts
Number of residents present: 9
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 10
Deficiencies: 3
Date: Jul 27, 2023
Visit Reason
The inspection was a renewal inspection conducted under new ownership to ensure staff training, care planning, and physical examinations are correct and up-to-date.
Findings
The inspection found non-compliance with applicable standards and laws, including failure to update resident agreements under new ownership, failure to maintain the interior of the building in good repair and cleanliness, and failure to ensure a complete first aid kit was on hand.
Deficiencies (3)
Facility failed to ensure new resident agreements were executed under new ownership as required by 22VAC40-73-390.
Facility failed to maintain the interior of the building in good repair and kept clean, including water stains, black spots on ceiling, stained carpeting, and rust-colored spots.
Facility failed to ensure a complete first aid kit was on hand; missing blanket, cold pack, and first aid instruction manual.
Report Facts
Residents present: 10
Resident records reviewed: 6
Staff records reviewed: 3
Resident agreements missing update: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Observed and confirmed deficiencies related to building maintenance and first aid kit contents |
Inspection Report
Monitoring
Census: 12
Deficiencies: 4
Date: May 12, 2023
Visit Reason
The inspection was a monitoring visit conducted on May 12, 2023, following a self-reported incident received on March 7, 2023, regarding allegations in the areas of Resident Care and Related Services.
Findings
The inspection found multiple violations including failure to ensure a dated discharge statement signed by the licensee or administrator, lack of written determination by a qualified mental health professional regarding meal options for residents with psychiatric conditions contributing to self-isolation, failure to store cleaning supplies and hazardous materials in locked areas, and failure to ensure residents do not keep hazardous materials accessible in their rooms. Photographic evidence supported these findings.
Deficiencies (4)
Failed to ensure a dated discharge statement signed by the licensee or administrator contained required notification details.
Failed to ensure a qualified mental health professional made a written determination regarding meal options for residents with psychiatric conditions contributing to self-isolation.
Failed to store cleaning supplies and other hazardous materials in a locked area, accessible to residents.
Failed to ensure a resident may keep cleaning supplies or hazardous materials in an out-of-sight place in his room if cognitively able, and to prevent access by other residents.
Report Facts
Number of residents present: 12
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Date of correction: Jun 29, 2023
Date of correction: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Interviewed staff who documented progress notes and acknowledged lack of room checks |
Inspection Report
Monitoring
Census: 12
Deficiencies: 3
Date: May 12, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations related to admission, retention, discharge of residents, emergency preparedness, and licensing requirements.
Findings
The inspection found non-compliance with applicable standards and laws, including deficiencies related to incomplete documentation of allergy reactions in physical examinations, lack of documented fire and emergency evacuation drills, and use of outdated facility signage.
Deficiencies (3)
The facility failed to ensure the physical examination contained a description of the person’s reactions to any known allergies.
The facility failed to ensure fire and emergency evacuation drill frequency and participation was in accordance with the Virginia Statewide Fire Prevention Code.
The facility failed to operate within the terms of the license including using the operating name of the facility.
Report Facts
Number of residents present: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Confirmed lack of documented fire and emergency evacuation drills |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 27, 2023
Visit Reason
Initial licensing inspection conducted to evaluate the facility's compliance with applicable standards and laws.
Findings
The inspection included a tour of the physical plant focusing on buildings and grounds. No violations were found with applicable standards or laws during this initial inspection.
Report Facts
Number of interviews conducted with staff: 3
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
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