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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.17
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,871
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0081
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.50% · Performance 21.75% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.05
Baseline 7.46% · Performance 5.43% · Measure score 8.05 · Achievement 8.05 · Improvement 7.75
Total nurse turnover
7.95
Baseline 45.36% · Performance 31.17% · Measure score 7.95 · Achievement 7.95 · Improvement 6.42
Adjusted total nurse staffing
5.36
Baseline 4.74 hours · Performance 4.60 hours · Measure score 5.36 · Achievement 5.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.7% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 296 · Observed rate 5.41% · Lower 95% interval 5.89% |
| Discharge to community | 49.29% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 276 · Observed rate 47.83% · Lower 95% interval 43.05% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.47% |
95.27%
1.8 pts worse
|
Numerator 272 · Denominator 291 |
| Falls with major injury | 0.34% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 291 |
| Discharge self-care score | 62.56% |
53.69%
8.9 pts better
|
Numerator 137 · Denominator 219 |
| Discharge mobility score | 61.64% |
50.94%
10.7 pts better
|
Numerator 135 · Denominator 219 |
| Pressure ulcers or injuries, new or worsened | 1.03% |
2.29%
1.3 pts better
|
Numerator 3 · Denominator 291 · Adjusted rate 1.12% |
| Healthcare-associated infections requiring hospitalization | 5.43% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 2.67% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 4.3% |
8.2%
3.9 pts worse
|
Numerator 11 · Denominator 256 |
| Staff flu vaccination coverage | 29% |
42%
13 pts worse
|
Numerator 134 · Denominator 462 |
| Discharge function score | 63.47% |
56.45%
7 pts better
|
Numerator 139 · Denominator 219 |
| Transfer of health information to provider | 98.46% |
95.95%
2.5 pts better
|
Numerator 64 · Denominator 65 |
| Transfer of health information to patient | 96.26% |
96.28%
About the same
|
Numerator 180 · Denominator 187 |
| Resident COVID-19 vaccinations up to date | 26.22% |
25.2%
1 pts better
|
Numerator 43 · Denominator 164 |
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 · Adjusted 0.9 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| 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 · Adjusted 0.7 · Observed 0.5 · Expected 1.2 · Used in QM five-star |
| 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 · Q1 98.1% · Q2 75.9% · Q3 65.5% · Q4 69.6% · 4Q avg 76.8% |
| 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 · 4Q avg 50.8% |
| 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 · Q1 3.8% · Q2 3.4% · Q3 5.2% · Q4 1.8% · 4Q avg 3.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 4.1% · 4Q avg 1.5% |
| 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 · Q1 5.6% · Q2 5.0% · Q3 8.6% · Q4 6.5% · 4Q avg 6.3% |
| 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 · Q1 7.9% · Q2 5.0% · Q3 11.4% · Q4 17.6% · 4Q avg 10.2% |
| 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 · Q1 21.9% · Q2 19.4% · Q3 20.0% · Q4 19.2% · 4Q avg 20.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 12.2% · Q2 31.9% · Q3 25.9% · Q4 13.8% · 4Q avg 21.8% · Used in QM five-star |
| 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 · Q1 13.9% · Q2 15.0% · Q3 14.7% · Q4 12.1% · 4Q avg 14.0% · Used in QM five-star |
| 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 · Q1 2.2% · Q2 3.1% · Q3 2.7% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| 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 · Q1 2.0% · Q2 1.7% · Q3 1.7% · Q4 3.8% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 31.7% · Q2 29.3% · Q3 35.9% · Q4 15.6% · 4Q avg 28.3% |
| 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 · Q1 0.0% · Q2 8.1% · Q3 8.1% · Q4 6.1% · 4Q avg 5.7% · Used in QM five-star |
| 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 · Q1 43.4% · Q2 29.1% · Q3 24.9% · Q4 35.9% · 4Q avg 33.2% |
| 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 · Adjusted 10.6% · Observed 9.5% · Expected 10.0% · Used in QM five-star |
| 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 · Q1 2.9% · Q2 2.9% · Q3 0.0% · Q4 0.8% · 4Q avg 1.7% · Used in QM five-star |
| 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 · 4Q avg 24.9% |
| 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 · Adjusted 25.4% · Observed 21.3% · Expected 19.9% · Used in QM five-star |
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
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#3
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0-star overall rating with 0-star inspections
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