VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lakewood Manor Baptist Retirement Community
1900 Lauderdale Drive
Richmond, VA 23238
(804) 740-2900

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: July 3, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-3-24 from 9:40 a.m.-2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-4-24 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 52 Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-x or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on a review of the resident?s record the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall. Evidence: The record for Resident # 1 contained charting notes that documented that the resident had two falls on 5-12-24 and one fall on 5-11-24. However, the resident?s record contained only one fall risk evaluation, dated 5-11-24.
Plan of Correction:	1. The resident sampled was missing a post fall assessment on May 11, 2024. The resident has since been discharged, but the post fall assessment was completed on July 3, 2024. 2. All residents have the potential to be affected by the deficient practice. A 100% audit of all current Assisted Living and Memory Support residents who have experienced falls was completed to ensure that post fall assessments had been completed. Any assessments within the last year that had not been completed were done. 3. All team members will be educated by July 26, 2024, on when to complete a post fall assessment on a resident: at least annually, when the condition of the resident changes, and after a fall. 4. AL Nurse Manager or designee will audit post fall assessments for their completion once a week for 4 weeks, then twice a month for two months and then quarterly for two quarters. Identified areas of concern will be corrected and re-education completed.