1 Inspection Summary
Inspection Reports Summary
Covers 13 inspections · Jun 2021 – Aug 2025Visit Reason
This report covers 13 inspections of Lakewood Manor Baptist Retirement Community from June 24, 2021 to August 5, 2025, including routine, monitoring, renewal, and complaint investigations.
Complaint Details
Five inspections were prompted by complaints regarding resident care and personnel. Some complaints were substantiated with violations issued; others were not supported by evidence.
Findings
Across that history VDSS cited 34 violations under 24 distinct standards. Five inspections were prompted by a complaint.
Deficiencies (34)
22VAC40-73-120-C: Staff training did not cover all required topics including emergency plans and infection control.
22VAC40-73-450-E: Individualized service plan (ISP) was not signed or dated by licensee or resident/legal representative.
22VAC40-73-950-E: No documentation of semi-annual emergency preparedness review for all staff and residents.
22VAC40-73-260-A: Direct care staff lacked documentation of current first aid certification.
22VAC40-73-325-A: Fall risk rating was not completed for residents meeting assisted living care criteria.
22VAC40-73-50-B: Written acknowledgment of receipt of disclosure was missing from resident records.
22VAC40-73-1090-A: No assessment by licensed psychologist or physician for serious cognitive impairment prior to admission.
22VAC40-73-410-A: Orientation acknowledgment for new residents was missing from records.
22VAC40-73-680-E: Medical procedures were not provided or documented according to physician orders.
22VAC40-73-210-B: Direct care staff did not attend required annual training hours.
22VAC40-73-430-H-2: Written discharge statement was not retained in resident record.
22VAC40-73-350-B: Sex offender screening was not documented prior to admission.
22VAC40-73-50-B: Written acknowledgment of disclosure receipt missing for multiple residents.
22VAC40-73-260-A: Staff lacked documentation of current first aid certification.
22VAC40-73-1100-A: Written approval for placement in secure environment was missing.
22VAC40-73-450-E: ISP not signed or dated by licensee or resident/legal representative; contributors not noted.
22VAC40-73-1090-A: Assessment for serious cognitive impairment missing for secure unit resident.
22VAC40-73-440-A: Uniform Assessment Instrument (UAI) was not completed prior to admission or annually.
22VAC40-73-550-G: Rights and responsibilities not reviewed annually with residents, legal representatives, or staff.
22VAC40-73-1110-B: Review of appropriateness of continued residence in special care unit was not performed.
22VAC40-73-410-A: Orientation acknowledgment missing for multiple residents.
22VAC40-73-320-A: Physical examination report prior to admission lacked required information.
22VAC40-73-325-B: Fall risk rating was not reviewed and updated after falls or condition changes.
22VAC40-73-260-A: Staff lacked documentation of current first aid certification.
22VAC40-73-120-C: Staff training did not include all required topics for initial orientation.
22VAC40-73-550-G: Staff did not acknowledge annual review of residents' rights and responsibilities.
22VAC40-73-460-E: Resident observations for changes in condition were not documented as required.
22VAC40-73-450-C: ISP did not describe services addressing all identified needs on UAI.
22VAC40-73-250-D: Staff TB risk assessments were outdated or missing documentation.
22VAC40-73-980-A: First aid kit lacked required items including instructional manual.
22VAC40-73-550-G: Residents' rights and responsibilities not reviewed annually with residents or representatives.
22VAC40-90-40-C: Staff with barrier crimes were employed despite criminal history reports.
22VAC40-73-440-A: UAI was not completed prior to resident admission as required.
22VAC40-73-210-F: Staff annual training did not include required infection control hours.
Report Facts
Violations cited: 34
Distinct standards: 24
Inspections on page: 13
Inspections with violations: 7
Complaint visits: 5
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