Inspection Report
Renewal
Census: 53
Deficiencies: 8
Aug 5, 2025
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 multiple violations related to resident assessments, staff training, documentation, and emergency preparedness. The facility failed to comply with several regulatory requirements, including assessments for cognitive impairment, staff training topics, first aid certification, fall risk assessments, resident orientation, individualized service plan signatures, and emergency preparedness reviews.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure prior assessment by a licensed clinical psychologist or physician for serious cognitive impairment for Resident #4. |
| Facility failed to retain written acknowledgment of receipt of disclosure by Resident #4 or legal representative. |
| Staff records showed incomplete training on required topics including emergency plans, infection control, and resident rights. |
| Direct care staff failed to maintain current certification in first aid (Staff #2 and Staff #3). |
| Resident #4 did not have a completed written fall risk rating by the time the comprehensive ISP was completed. |
| Resident #4 lacked documentation of acknowledgment of orientation upon admission. |
| Individualized service plan for Resident #4 was not signed or dated by licensee, administrator, or designee. |
| Facility failed to provide documentation of a semi-annual review on emergency preparedness and response plan for all staff. |
Report Facts
Number of residents present: 53
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 4
Inspection Report
Monitoring
Census: 51
Deficiencies: 1
Apr 15, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by the VDSS Division of Licensing regarding allegations in the area of resident care.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations being issued. Specifically, the facility failed to ensure that medical procedures or treatments ordered by a physician were provided according to instructions and documented.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to instructions and documented. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 1
Number of interviews conducted: 2
Inspection Report
Monitoring
Census: 51
Deficiencies: 13
Dec 10, 2024
Visit Reason
The inspection was a monitoring visit conducted on December 10 and December 12, 2024, to review compliance with applicable standards and laws at Lakewood Manor Baptist Retirement Community.
Findings
The inspection found multiple violations related to resident assessments, approvals for placement in secure environments, staff training, documentation of resident rights, and other regulatory requirements. The facility was found non-compliant in several areas, with documented violations and plans of correction required.
Deficiencies (13)
| Description |
|---|
| Failure to ensure residents admitted to a safe, secure environment were assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Failure to obtain written approval for placement of residents with serious cognitive impairment in a safe, secure environment. |
| Failure to perform six-month and annual reviews of appropriateness of continued residence in the special care unit. |
| Failure to retain written acknowledgment of receipt of disclosure by residents or legal representatives. |
| Failure to ensure direct care staff attended required annual training hours. |
| Failure to maintain current first aid certification for direct care staff. |
| Failure to ensure physical examination reports contained all required elements within 30 days preceding admission. |
| Failure to ascertain and document sex offender status prior to admission. |
| Failure to provide orientation to new residents and legal representatives including emergency procedures and obtain signed acknowledgment. |
| Failure to retain a copy of the written discharge statement in resident records. |
| Failure to complete the Uniform Assessment Instrument (UAI) prior to admission and annually. |
| Failure to ensure individualized service plans (ISP) were signed and dated by required parties. |
| Failure to review annually the rights and responsibilities of residents with residents, legal representatives, and staff, and retain written acknowledgments. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 6
Number of interviews conducted with residents: 2
Number of staff records reviewed: 3
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jul 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-06-04 regarding allegations in the area of resident care.
Findings
The investigation supported some, but not all, of the allegations. The facility failed to ensure that the fall risk rating was reviewed and updated as required, specifically missing post-fall assessments for a resident who had multiple falls.
Complaint Details
The complaint was substantiated in part; the facility did not complete required post-fall assessments for a resident who had multiple falls on 2024-05-11 and 2024-05-12. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that the fall risk rating was reviewed and updated at least annually, when the resident's condition changed, and after a fall, as evidenced by missing post-fall assessments for Resident #1. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Jun 14, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the area of resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
The complaint was related to resident care. The investigation found no substantiation of the allegations.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Monitoring
Deficiencies: 0
Mar 1, 2024
Visit Reason
An unannounced monitoring inspection was conducted to observe the facility's memory care unit renovations and to complete a tour and measurements of the physical plant.
Findings
The inspection found no violations with applicable standards or laws. The inspection summary will be posted publicly within five business days.
Inspection Report
Monitoring
Census: 53
Deficiencies: 0
Jan 11, 2024
Visit Reason
The inspection was a monitoring visit conducted to review a self-reported incident received by VDSS regarding allegations in the area of resident care.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The identified resident was observed participating in a memory care activity.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Aug 10, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on July 3, 2023, regarding allegations related to personnel at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within five business days of receipt.
Complaint Details
A complaint was received on July 3, 2023, concerning personnel issues. The evidence gathered did not substantiate the allegations.
Report Facts
Number of residents present: 54
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 54
Deficiencies: 3
Aug 10, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable regulations and laws.
Findings
The inspection found non-compliance with applicable standards and laws, specifically related to staff training, certification, and annual review of residents' rights and responsibilities. Violations were documented and a violation notice was issued to the facility.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure all staff were trained in relevant laws, regulations, and facility policies including emergency plans, infection control, and resident rights. |
| Facility failed to ensure each direct care staff member maintained current certification in first aid. |
| Facility failed to ensure annual review of residents' rights and responsibilities was conducted and documented for staff. |
Report Facts
Residents present: 54
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Apr 14, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 23, 2023, regarding allegations in the areas of resident care and personnel.
Findings
The investigation supported some, but not all, of the allegations related to resident care. A violation notice was issued for failure to regularly observe residents for changes in physical, mental, emotional, and social functioning, specifically noting lack of documentation for Resident #1's observation and care.
Complaint Details
The complaint was partially substantiated with non-compliance found in resident care. The violation was not related to the complaint but identified during the investigation. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure regular observation and documentation of residents' changes in condition, including failure to document a skin tear observed on Resident #1. |
Report Facts
Number of residents present: 50
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Apr 14, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing regarding allegations related to resident care and personnel at the facility.
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 within five business days of receipt.
Complaint Details
Complaint related to allegations in the areas of resident care and personnel; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 61
Deficiencies: 7
Aug 19, 2022
Visit Reason
The inspection was a renewal inspection conducted to evaluate compliance with applicable standards and regulations for the assisted living facility license renewal.
Findings
The inspection identified multiple violations related to staff training, tuberculosis screening, resident assessments, individualized service plans, resident rights acknowledgments, first aid kit contents, and background checks. Plans of correction were provided for each deficiency to ensure future compliance.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure at least two hours of direct care staff annual training focused on infection control and prevention. |
| Facility failed to ensure each staff person annually submitted results of a tuberculosis risk assessment. |
| Facility failed to ensure all residents were assessed face to face using the uniform assessment instrument (UAI) prior to admission. |
| Individualized service plan (ISP) did not contain a written description of services to address all identified needs on the UAI. |
| Facility failed to ensure resident rights and responsibilities were reviewed annually with written acknowledgment filed in the resident's record. |
| First aid kit did not contain the required First Aid instructional manual. |
| Facility failed to ensure persons with barrier crimes on criminal history reports were ineligible for employment; one staff member with a barrier crime was employed. |
Report Facts
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of residents present: 61
Date of hire for Staff #1: March 24, 2009
Date of hire for Staff #3: October 3, 2017
Date of hire for Staff #4: November 3, 2003
Date of hire for Staff #5: September 14, 2021
Inspection Report
Monitoring
Census: 55
Deficiencies: 0
Jun 24, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, facility documentation, medication administration records, physician orders, and criminal history records, determining no violations with applicable standards or law. No violations were issued.
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