Cycle 1
Health 2023-06-23 · Fire 2023-06-23
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Richmond, VA
Lakewood Manor
3-star overall rating with 3-star inspections with 3 recent health deficiencies
1900 Lauderdale Drive, Richmond, VA
(804) 740-2900
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
85
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-04-20
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
1.38
Licensed practical nurse staffing
Aide hours / resident day
2.61
Nurse aide staffing
Weekend hours
4.17
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.8% |
91.2%
14.4 pts worse
|
93.4%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 50.8% |
94.0%
43.2 pts worse
|
95.5%
44.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.6%
About the same
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
15.7%
14.2 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.7%
0.6 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
20.2%
10 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
15.0%
5.2 pts worse
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
17.5%
4.3 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
15.7%
1.7 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.5%
1.5 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.6%
0.7 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
22.2%
6.1 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.2%
0.5 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.2% |
74.6%
41.4 pts worse
|
81.7%
48.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.7%
1.1 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 24.9% |
73.6%
48.7 pts worse
|
79.7%
54.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
22.0%
3.4 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-01 · Fire 2021-04-01
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-08-16 · Fire 2018-08-16
4 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-04-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-05-07
E · Potential for more than minimal harm
2018-08-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-11-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-06-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-20
C · Minimal harm
2023-06-23
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-07-20
G · Actual harm
2021-04-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-06-16
E · Potential for more than minimal harm
2021-04-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-01
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-16
D · Potential for more than minimal harm
2018-08-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-09-28
D · Potential for more than minimal harm
2018-08-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-09-28
D · Potential for more than minimal harm
2018-08-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-09-28
D · Potential for more than minimal harm
2018-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-28
Penalties and ownership
What sits behind the stars
Ownership
Virginia Baptist Homes Inc
5% Or Greater Direct Ownership Interest · Organization
Albritton, Tracey
Corporate Officer · Individual
Bales, James
Corporate Director · Individual
Brooks, Sharon
Corporate Director · Individual
Browning, Herbert
Corporate Director · Individual
Carlton, Daniel
Corporate Officer · Individual
Carter, Valerie
Corporate Director · Individual
Cave, R
Corporate Director · Individual
Cook, Jonathan
Corporate Officer · Individual
Franks, Tiffany
Corporate Director · Individual
Harris, Charles
Corporate Director · Individual
Hawthorne, Lisa
Corporate Officer · Individual
Jung, John
Corporate Director · Individual
Keck, Michael
Corporate Director · Individual
Marchello, Sallie
Corporate Director · Individual
Markwith, Christopher
Corporate Officer · Individual
Moran, Christine
Corporate Officer · Individual
Oakey, Samuel
Corporate Director · Individual
Owens, Arne
Corporate Director · Individual
Poats, Jim
Corporate Director · Individual
Poma, John
Corporate Director · Individual
Robinson, John
Corporate Officer · Individual
Rusnak, Heather
W-2 Managing Employee · Individual
Scott, Matthew
Corporate Director · Individual
Thomson, Gary
Corporate Director · Individual
Virginia Baptist Homes Inc
Operational/Managerial Control · Organization
Nearby options
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Richmond, VA
1-star overall rating with 1-star inspections with $92,980 in total fines with 40 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Shalom Gardens Health & Rehabilitation
Richmond, VA
4-star overall rating with 4-star inspections with $12,177 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Cedarfield Pinnacle Living
Richmond, VA
0-star overall rating with 0-star inspections
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