Inspection Reports for
Lakeside ALF Operations, LLC
2125 Hilliard Road, HENRICO, VA, 23228
Back to Facility Profile4 Reports · 1 Summary
Inspection Summary
8 inspections covered, Jan 2023 – Jun 2025.
Inspection Reports Summary
Visit Reason
This report covers 8 inspections of Lakeside ALF Operations, LLC from January 27, 2023 to June 4, 2025, including routine and complaint investigations.
Complaint Details
Two complaint surveys were conducted on March 4, 2024 and August 15, 2024. Both investigations found no violations. The March 4, 2024 complaint involved medication labeling and housekeeping; the August 15, 2024 complaint involved resident care and physical conditions but was not substantiated.
Findings
Across that history VDSS cited 11 violations under 11 distinct standards. Two inspections were prompted by a complaint.
Deficiencies (11)
22VAC40-73-450-E: Individual service plan lacked required signatures from licensee and resident/legal representative.
22VAC40-73-980-A: Facility failed to ensure a complete first aid kit was on hand.
22VAC40-73-870-A: Interior of building was not maintained in good repair and kept clean.
22VAC40-73-40-D-2: New resident agreements were not completed after facility ownership change.
22VAC40-80-120-A-1: Facility failed to operate within license terms including use of operating name.
22VAC40-73-320-A: Physical exam lacked description of reactions to known allergies.
22VAC40-73-970-A: Fire and emergency evacuation drills not conducted as required.
22VAC40-73-860-I: Cleaning supplies and hazardous materials were not stored in a locked area.
22VAC40-73-430-H-1: Discharge statement lacked required dates and signatures.
22VAC40-73-580-B: No written determination by mental health professional on meal options for resident with psychiatric condition.
22VAC40-73-860-J: Resident's cleaning supplies/hazardous materials were accessible to other residents.
Report Facts
Violations cited: 11
Distinct standards: 11
Inspections on page: 8
Inspections with violations: 4
Complaint visits: 2
Individual Reports
One document per inspection visit.
Inspection Report — Aug 1, 2024
Complaint Investigation
Date: Aug 1, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident rights, facility environment, staff practices, and safety issues including failure to allow residents to make treatment decisions, failure to maintain a safe and homelike environment, failure to timely report allegations of illegal drug use, failure to meet professional standards of care, and failure to provide adequate incontinence care.
Complaint Details
The investigation was complaint-driven based on concerns about resident rights violations, unsafe and unsanitary environment, failure to report illegal drug use, inadequate care and monitoring, and equipment failures affecting resident safety and comfort.
Findings
The facility was found to have multiple deficiencies including failure to respect resident rights to make treatment decisions, inadequate monitoring of residents, failure to maintain a safe, clean, and comfortable environment with pest infestations and equipment issues, failure to timely report allegations of illegal drug use, and failure to provide adequate incontinence care for dependent residents. Mechanical lifts were often nonfunctional and had to be borrowed from other units, causing delays in care.
Deficiencies (6)
F 0552: The facility failed to allow Resident #1 to make decisions regarding his treatment for shortness of breath, resulting in minimal harm.
F 0584: The facility failed to maintain a safe, clean, and homelike environment for Residents #2, #6, and #9, including issues with temperature control, pest infestations, leaking ceilings, and nonfunctional equipment.
F 0609: The facility failed to timely report allegations of residents receiving illegal drugs for Residents #7 and #8, resulting in minimal harm.
F 0658: The facility failed to meet professional standards by inadequately assessing and monitoring Resident #1 during a change in condition.
F 0677: The facility failed to provide evidence of incontinence care for dependent Residents #3, #4, and #9, with missing documentation and resident reports of prolonged exposure to urine and feces.
F 0921: The facility failed to ensure a safe, comfortable temperature and functional equipment for Residents #2, #6, and #9, including nonfunctional mechanical lifts, pest infestations, leaking ceilings, and inadequate air conditioning.
Report Facts
German cockroach counts: 38
German cockroach counts: 16
German cockroach counts: 88
German cockroach counts: 46
German cockroach counts: 51
BIMS score: 15
BIMS score: 8
BIMS score: 15
BIMS score: 13
BIMS score: 14
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in Resident #1 treatment decision and monitoring deficiency |
| LPN #4 | Unit Manager | Named in Resident #1 monitoring deficiency |
| ASM #4 | Nurse Practitioner | Interviewed regarding resident hospital transfers |
| ASM #7 | Medical Director | Interviewed regarding resident hospital transfers |
| ASM #1 | Administrator | Made aware of multiple concerns and deficiencies |
| ASM #2 | Director of Nursing | Made aware of multiple concerns and deficiencies |
| ASM #6 | Regional Director of Clinical Operations | Made aware of multiple concerns and deficiencies |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding environment and equipment issues |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding mechanical lift availability |
| OSM #2 | Maintenance Director | Interviewed regarding facility environment and leaking ceiling |
Inspection Report — Feb 28, 2024
Routine
Date: Feb 28, 2024
Visit Reason
Routine inspection of Lakeside Health & Rehabilitation to assess compliance with regulatory standards including resident care, facility maintenance, medication administration, and other health and safety requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain call lights within reach, inadequate room repairs, incomplete and inaccurate MDS assessments, failure to implement comprehensive care plans, medication administration delays, lack of trauma informed care, insufficient social services, improper food handling, and failure to provide dental services.
Deficiencies (13)
F 0558: Facility staff failed to maintain the call light within reach of Resident #145 as required by the care plan.
F 0584: Facility staff failed to maintain resident rooms in good repair on the Arcadia unit, including missing closet slats, torn wallpaper, missing drawer fronts, holes in walls, and damaged floor tiles.
F 0641: Facility staff failed to complete a discharge MDS assessment for Resident #42 and failed to code dialysis services on the quarterly MDS for Resident #120.
F 0656: Facility staff failed to implement comprehensive care plans for Residents #60, #188, and #166, including oxygen administration, incontinence care, and timely medication administration.
F 0688: Facility staff failed to provide treatment and services to maintain or improve mobility for Resident #66 by inconsistent application of a left-hand splint.
F 0695: Facility staff failed to administer oxygen at the prescribed rate of 2 liters per minute for Resident #60.
F 0677: Facility staff failed to provide consistent incontinence care for Resident #188 in November 2022.
F 0697: Facility staff failed to provide a complete pain management program for Resident #169, including timely medication administration and appropriate follow-up.
F 0699: Facility staff failed to provide trauma informed care for Residents #169 and #159, including failure to initiate trauma informed care plans and provide social services.
F 0745: Facility staff failed to provide medically related social services for Residents #169 and #159, including lack of routine social work notes and follow-up.
F 0790: Facility staff failed to assist Resident #102 with obtaining routine dental care since admission.
F 0812: Facility staff failed to store and serve food in a sanitary manner in the kitchen, including uncovered cheese, uncovered flour scoop, uncovered hair and beard, and improper glove use during meal service.
F 0758: Facility staff failed to ensure Residents #23 and #107 were free from unnecessary antipsychotic medications by not identifying or monitoring specific behaviors for medication use.
Report Facts
Residents in survey sample: 49
Behavior monitoring opportunities for R23: 81
Behavior monitoring occurrences for R23: 60
Behavior monitoring opportunities for R107: 81
Behavior monitoring occurrences for R107: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | MDS Coordinator | Interviewed regarding missing MDS assessments and care plan implementation |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding call bell procedures and medication administration |
| RN #3 | Registered Nurse | Interviewed regarding medication administration and trauma informed care |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding splint application and incontinence care |
| OSM #1 | Dietary Manager | Interviewed regarding food handling and kitchen sanitation |
| OSM #3 | Director of Social Services | Interviewed regarding dental services and trauma informed care |
| OSM #11 | Assistant Director of Social Services | Interviewed regarding trauma informed care process |
| LPN #11 | Unit Manager | Interviewed regarding behavioral monitoring documentation |
Inspection Report — May 23, 2022
Complaint Investigation
Date: May 23, 2022
Visit Reason
Complaint investigation triggered by concerns about locked units restricting resident freedom and other regulatory compliance issues.
Complaint Details
Complaint investigation included concerns about locked units restricting resident freedom, failure to notify providers and representatives of resident status changes, failure to maintain clean environments, failure to implement care plans, failure to meet staff vaccination requirements, and medication errors.
Findings
The facility failed to ensure residents' rights to freedom of movement on locked units, failed to notify providers and representatives of resident status changes, failed to maintain clean environments, failed to implement care plans, and failed to meet staff vaccination requirements.
Deficiencies (19)
F0540 - Facility failed to ensure residents' freedom of movement on locked units; residents required staff to enter codes to exit locked areas without proper behavioral assessments for all.
F0550 - Facility failed to promote Resident #105's right to a dignified existence by restricting freedom of movement and access to codes to exit locked units.
F0558 - Facility failed to keep Resident #317's call bell within reach, limiting ability to call for assistance.
F0622 - Facility failed to provide required resident transfer documentation to receiving hospitals for multiple residents.
F0580 - Facility failed to notify resident representatives and ombudsman in writing of resident transfers to hospitals for multiple residents.
F0625 - Facility failed to provide written notice of bed hold policies at time of discharge for multiple residents transferred to hospitals.
F0687 - Facility failed to provide foot care services for Resident #30; toenails were long, thick, and not trimmed by podiatrist as scheduled.
F0684 - Facility failed to maintain clean privacy curtains and working overhead light in Resident #85's room.
F0812 - Facility failed to hold quarterly QAPI committee meetings in 2020, 2021, and first quarter 2022 as required.
F0730 - Facility failed to provide mandatory annual training for two of five CNAs reviewed.
F0802 - Facility failed to maintain sufficient dietary staff to meet resident needs at lunch on 7/5/22, resulting in improper meal preparation and serving.
F0804 - Facility failed to serve meals in a palatable manner; food temperatures were often below safe and appetizing levels.
F0806 - Facility failed to honor Resident #102's food preferences; resident received untasted food and disliked items without alternatives.
F0656 - Facility failed to implement Resident #16's dialysis care plan including monitoring AV fistula site and completing dialysis communication forms.
F0698 - Facility failed to provide complete dialysis services and communication for Resident #149; dialysis communication forms were incomplete or missing.
F0947 - Facility failed to provide annual performance evaluations for five CNAs reviewed.
F0883 - Facility failed to offer, obtain consent for, and provide education regarding influenza and pneumococcal vaccines for two residents.
F0888 - Facility staff failed to meet COVID-19 vaccination requirements for 11 of 166 employees; failed to provide evidence of exemption approvals.
F0675 - Facility failed to ensure Resident #102's blood pressure medication was held when parameters were met, risking harm.
Report Facts
Residents tested positive for COVID-19: 15
Employee vaccination exemptions pending: 11
Residents in locked units: 83
Residents on second floor unit records reviewed: 50
Residents assessed as exit seeking: 1
Deficiency counts: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ASM #1 | Administrator | Named in multiple interviews regarding locked units, resident rights, and QAPI meetings |
| ASM #2 | Director of Nursing | Named in multiple interviews regarding locked units, resident rights, vaccination, and care plans |
| ASM #3 | Quality Assurance Consultant | Named in interviews regarding locked units and quality assurance |
| LPN #2 | Licensed Practical Nurse | Named in interviews regarding locked units and resident safety |
| LPN #5 | Licensed Practical Nurse | Named in interview regarding dialysis communication forms and care plan implementation |
| LPN #6 | Licensed Practical Nurse | Named in interview regarding podiatry services |
| LPN #7 | Licensed Practical Nurse | Named in interview regarding delayed X-ray and communication with provider |
| RN #1 | Registered Nurse | Named in interview regarding hospital transfer documentation and medication administration |
| OSM #2 | Human Resources Director | Named in interviews regarding vaccination exemptions and employee records |
| OSM #4 | Social Services Worker | Named in interviews regarding hospital transfer notification and podiatry scheduling |
| OSM #5 | Temporary Dietary Manager | Named in interview regarding meal preparation and resident food preferences |
| OSM #6 | Dietary Manager | Named in interview regarding meal preparation and food safety |
Inspection Report — May 2, 2019
Complaint Investigation
Date: May 2, 2019
Visit Reason
The inspection was conducted based on complaint investigations and routine oversight to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility operations.
Complaint Details
The inspection included complaint investigations related to resident dignity, medication administration errors, infection control, and hospice care.
Findings
The facility was found deficient in multiple areas including failure to serve residents with dignity, failure to notify physicians of changes in condition, medication administration errors, incomplete assessments, inadequate care planning, infection control lapses, expired supplies, improper food handling, and failure to provide comprehensive hospice care.
Deficiencies (18)
F 0550: Facility staff failed to serve two residents their meals in a timely manner, causing them to wait while others at their table ate, violating resident dignity.
F 0580: Facility staff failed to notify physicians and responsible parties of changes in condition related to insulin administration and medication holds for four residents.
F 0582: Facility staff failed to provide timely notice of Medicare non-coverage to two residents and their representatives.
F 0584: Facility staff failed to provide a homelike environment for a resident by not providing a nightstand in the resident's room.
F 0622: Facility staff failed to provide required documentation and notifications to the receiving hospital and ombudsman for a resident's transfer.
F 0641: Facility staff failed to ensure accurate and complete MDS assessments for two residents, including failure to complete cognitive assessments and correct coding.
F 0656: Facility staff failed to develop and implement comprehensive care plans for six residents, including failure to follow insulin administration plans and failure to address implanted cardiac device care.
F 0684: Facility staff failed to ensure continuity of care and collaboration with hospice services for one resident, lacking hospice documentation and communication.
F 0690: Facility staff failed to provide appropriate care for a resident with a suprapubic catheter, including failure to keep catheter bag off the floor and failure to store nasal cannula in a sanitary manner.
F 0695: Facility staff failed to provide oxygen according to physician orders for one resident and failed to store nasal cannula properly for another resident.
F 0697: Facility staff failed to implement non-pharmacological interventions prior to administering as needed pain medication to a resident.
F 0757: Facility staff failed to ensure residents were free from unnecessary drugs by administering insulin outside physician parameters and failing to notify physicians.
F 0772: Facility staff failed to ensure expired laboratory supplies were removed from medication supply rooms.
F 0812: Facility staff failed to ensure hair was fully covered in the food preparation area, including uncovered beard.
F 0849: Facility staff failed to properly dispose of garbage and refuse, leaving trash around dumpsters.
F 0880: Facility staff failed to provide comprehensive hospice services for a resident, lacking documentation and collaboration with hospice.
F 0880: Facility staff failed to implement infection control practices during wound care and food service, including failure to keep wound area clean, thumbs off food surfaces, and hand hygiene.
F 0880: Facility staff failed to follow infection control practices for respiratory equipment and urinary catheter care for a resident.
Report Facts
Deficiencies cited: 17
Resident sample size: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in medication administration and care plan findings related to insulin administration. |
| LPN #5 | Licensed Practical Nurse | Named in medication administration and care plan findings related to insulin administration. |
| RN #6 | Unit Manager | Named in medication administration and hospice care findings. |
| RN #8 | Wound Care Nurse | Named in wound care and infection control findings. |
| OSM #4 | Food Service Manager | Named in food safety and sanitation findings. |
| OSM #7 | Dietary Manager | Named in food service hygiene findings. |
| ASM #2 | Mobile Administrator | Named in multiple findings awareness and interviews. |
5 CMS Surveys
CMS Survey — Feb 28, 2024
Feb 28, 2024
CMS Survey — Aug 1, 2024
Aug 1, 2024
CMS Survey — May 2, 2019
May 2, 2019
CMS Survey — May 23, 2022
May 23, 2022
CMS Survey — Feb 28, 2024
Feb 28, 2024
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