Deficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Jun 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a self-report received on 05/18/2025 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards and laws, specifically that the facility failed to report a major incident within 24 hours as required. The incident involved a resident overdose requiring hospitalization.
Complaint Details
The complaint investigation was substantiated based on a self-report of an incident on 04/18/2025 involving a resident overdose requiring hospitalization. The facility failed to report the incident within the required 24-hour timeframe.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure reporting to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
Report Facts
Number of residents present: 87
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of resident interviews conducted: 8
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation and named in the report |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Jun 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 06/25/2027 regarding allegations in the area of Buildings and Grounds.
Findings
The inspection found non-compliance with applicable standards and laws, including the facility not having a licensed administrator of record and failure to develop and implement a plan to protect residents from heat- and cold-related illnesses during loss of air-conditioning or heating.
Complaint Details
The complaint was substantiated as the inspection confirmed violations related to administration and building conditions, including lack of a licensed administrator and inadequate emergency temperature control plans.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure that the facility shall have an administrator of record; staff #1 was acting administrator for more than 90 days without passing the licensing test. |
| The facility did not ensure to develop and implement a plan to protect residents from heat-related and cold-related illnesses in the event of loss of air-conditioning or heat due to emergency situations or malfunctioning equipment. |
Report Facts
Number of residents present: 87
Number of resident interviews: 8
Number of staff interviews: 2
Days acting as administrator without license: 90
Temperature threshold exceeded: 80
Scheduled repair date: Jul 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff #1 | Acting Administrator waiting to take licensing test and confirming air conditioning issues |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Mar 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on a report received regarding infestations of insects and vermin at the facility.
Findings
The facility was found to be non-compliant with standards related to maintaining the buildings free of infestations of insects and vermin, specifically bed bugs. Staff confirmed the presence of bed bugs and provided pest control treatment reports.
Complaint Details
Complaint related: Yes. A complaint was received that the facility has bed bugs and does not provide appropriate PPE for residents and staff. Staff #1 confirmed the presence of bed bugs and provided pest control treatment reports.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure the buildings were kept free of infestations of insects and vermin, specifically bed bugs, and did not provide appropriate PPE for residents and staff. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Named as the current inspector conducting the complaint investigation. |
| Staff #1 | Confirmed the presence of bed bugs and provided pest control reports. |
Inspection Report
Renewal
Census: 86
Deficiencies: 8
Jan 5, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff tuberculosis screening, sex offender registry checks, resident rights documentation, medication management, first aid kit completeness and checks, sworn statements for employment, and criminal history record reports. Plans of correction were submitted for all deficiencies.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure staff submitted tuberculosis risk assessment documentation on or within seven days prior to first day of work. |
| Facility did not ensure sex offender registry check was completed prior to admission and documented in resident record. |
| Facility did not ensure annual review of rights and responsibilities of residents and staff with proper documentation. |
| Facility did not have a current, implemented written plan for medication management; expired medication found. |
| First aid kit did not contain all required items during inspection. |
| Facility did not ensure monthly checks of first aid kits with documentation. |
| Sworn statements or affirmations were not completed for all employment applicants. |
| Criminal history record reports were not obtained on or prior to the 30th day of employment for several staff. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of resident interviews: 2
Number of staff interviews: 3
Number of residents observed during medication pass: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff #1 | Acknowledged missing TB documentation, sex offender registry check, missing resident rights documentation, confirmed expired medication, confirmed missing first aid kit items, confirmed missing sworn statement, and missing criminal record reports. | |
| Staff #3 | Confirmed expired medication and missing resident rights documentation. | |
| Staff #10 | Missing TB documentation and resident rights documentation. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Feb 28, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing on 2024-02-07 regarding allegations in the area of Resident Care and Related Services.
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 and a copy is required to be posted on the facility premises.
Complaint Details
Two complaints were received alleging issues in Resident Care and Related Services. The investigation found no substantiation of non-compliance.
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Jan 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-03 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint received on 2024-01-03 regarding Resident Care and Related Services; evidence did not support the allegations.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 85
Deficiencies: 11
Jan 11, 2024
Visit Reason
The inspection was a renewal inspection conducted on January 11 and 12, 2024, to assess compliance with applicable regulations and licensing requirements for Indian River Assisted Living.
Findings
The inspection found multiple violations including unsecured maintenance closets with harmful materials accessible to residents, incomplete staff certification and tuberculosis screening records, failure to post complete resident rights, expired medications in medication carts, discrepancies in controlled drug counts, building maintenance issues, incomplete first aid kit checks, and delayed criminal history record reports for some staff.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure harmful materials were inaccessible to residents; maintenance closets were left unlocked with paint and cleaning supplies accessible. |
| Facility failed to obtain required certification documentation for direct care staff in personnel records. |
| Facility failed to ensure tuberculosis risk assessments were completed for new staff prior to first day of work. |
| Facility failed to post the complete rights and responsibilities of residents conspicuously in a public place. |
| Facility failed to ensure annual review of resident rights and responsibilities was documented for certain residents. |
| Facility failed to post dated menus for meals for the current week in an area conspicuous to residents. |
| Facility failed to prevent use of outdated medications and ensure accurate counts of controlled substances; multiple expired medications observed and discrepancies in narcotic counts found. |
| Facility failed to maintain interior and exterior of buildings in good repair; issues included missing and chipped tiles, broken blinds and dresser, cracked floor tiles, and blocked emergency exit. |
| Facility failed to ensure monthly checks of first aid kits were documented. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for several staff members. |
| Facility employed a staff member convicted of misdemeanor barrier crimes, who was subsequently terminated. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 3
Expired medications observed: 7
Medication count discrepancies: 2
Staff without timely criminal history report: 1
Staff terminated for barrier crimes: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Direct Care Staff | Named in deficiency for lacking certification documentation |
| Staff #4 | Acknowledged discrepancies in controlled drug record counts and unable to provide documentation of monthly first aid kit checks | |
| Staff #5 | Acknowledged lack of certification documentation for Staff #3 and training verified by training school | |
| Staff #6 | Criminal history record report completed late (after 30th day of employment) | |
| Staff #7 | Criminal history record report completed late (after 30th day of employment) | |
| Staff #8 | Criminal history record report not completed at time of inspection | |
| Staff #9 | Convicted of misdemeanor barrier crimes and terminated |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Dec 11, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-12-06 regarding allegations in the area of Resident Care and Related Services.
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 5 business days of receipt.
Complaint Details
Complaint investigation related to allegations in Resident Care and Related Services; the complaint was not substantiated.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 86
Deficiencies: 3
Nov 6, 2023
Visit Reason
The inspection was a monitoring visit conducted on November 6, 2023, following a self-reported incident received on October 25, 2023, regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to mandated reporting of abuse, background checks for employees, and obtaining criminal history record reports for new hires.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents as required by law. |
| Facility failed to ensure no employee worked in a position involving direct resident contact without a completed background check. |
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for an employee. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 83
Deficiencies: 1
Oct 19, 2023
Visit Reason
The inspection was a monitoring visit conducted on October 19, 2023, following a self-reported incident received on October 4, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards or laws, specifically that the facility failed to ensure a resident's comprehensive individualized service plan included a description of identified needs. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure resident's comprehensive individualized service plan included a description of identified needs, including physical assistance with dressing and toileting, supervision with transferring, wandering, and need for a wanderguard. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 3, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-08-01 regarding allegations in the area of Resident Care and Related Services.
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.
Complaint Details
Complaint received on 2023-08-01 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
May 2, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-03-23 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.
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 and a copy is required to be posted on the facility premises.
Complaint Details
Complaint received on 2023-03-23 regarding allegations in Administration and Administrative Services and Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 92
Deficiencies: 19
Dec 13, 2022
Visit Reason
The inspection was a renewal inspection conducted on December 13, 15, and 19, 2022, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including unsecured hazardous materials, incomplete resident and staff records, failure to maintain required documentation and certifications, facility maintenance issues, and staff background check deficiencies. Plans of correction were proposed for each violation to restore compliance.
Deficiencies (19)
| Description |
|---|
| Facility failed to ensure harmful materials were inaccessible to residents except under staff supervision. |
| Facility failed to retain written acknowledgment of receipt of disclosure by residents or legal representatives. |
| Direct care staff did not complete required annual training hours. |
| Staff tuberculosis risk assessments were not current. |
| Listing of staff with current first aid or CPR certification was not posted. |
| Facility failed to provide written assurance of appropriate license to meet resident care needs prior to admission. |
| Facility failed to ascertain and document sex offender status prior to admission for certain residents. |
| Facility lacked written agreement/acknowledgment of notification signed by resident or legal representative at admission. |
| Facility failed to provide orientation to new residents and legal representatives upon admission. |
| Facility failed to review resident rights and responsibilities annually with residents or legal representatives. |
| Menus for meals were not dated and posted in a conspicuous area. |
| Facility failed to maintain a current diet manual with acceptable nutrition practices. |
| Hot water taps were not maintained within the required temperature range. |
| Interior and exterior of buildings were not maintained in good repair and clean condition. |
| Facility failed to ensure adequate lighting in all interior and exterior areas. |
| First aid kit on transport vehicle lacked required items. |
| Facility failed to document staff participation in emergency practice exercises at least every six months. |
| Criminal history record reports were not obtained on or prior to the 30th day of employment for several staff. |
| Facility employed a staff member convicted of a felony barrier crime. |
Report Facts
Number of residents present: 92
Number of resident records reviewed: 5
Number of staff records reviewed: 10
Staff training hours: 3.75
Staff tuberculosis risk assessment date: Jan 28, 2021
Hot water temperature: 128
Hot water temperature: 100
Number of lights out: 3
Staff without criminal history record report: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 7
Aug 29, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-08-16 regarding allegations in staffing and supervision, resident care and related services, and buildings and grounds.
Findings
The investigation did not substantiate the complaint allegations; however, several violations unrelated to the complaint were identified during the inspection, including unsecured harmful materials, failure to post required documents, outdated menus, foul odors, maintenance issues, and inadequate lighting.
Complaint Details
Complaint was received on 2022-08-16 regarding staffing and supervision, resident care and related services, and buildings and grounds. The evidence gathered did not support the allegations of non-compliance.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure that ordinary materials or objects harmful to residents were inaccessible except under staff supervision; bleach left unattended in dining area and maintenance and employee rooms left unlocked containing paint supplies. |
| Facility failed to post certain documents related to the terms of the license, including the most recent license and inspection findings. |
| Facility failed to post the name of the current on-site person in charge as required; staff person in charge was not present during inspection. |
| Facility failed to post a current menu including snacks in a conspicuous area; menu posted was for previous day and did not list snacks. |
| Facility failed to ensure the building was free from foul, stale, and musty odors; strong urine odor noted on south hall. |
| Facility failed to maintain interior and exterior of buildings in good repair and free of rubbish; missing tiles, peeling paint, wet towels on floor, slippery and muddy floors observed. |
| Facility failed to ensure all interior and exterior areas were adequately lighted; blown and flickering light bulbs noted on south hall and bathroom. |
Report Facts
Number of residents present: 94
Number of resident records reviewed: 3
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Inspection Report
Routine
Deficiencies: 1
Feb 6, 2022
Visit Reason
An unannounced non-mandated complaint inspection was conducted to review compliance with regulations and investigate a complaint, which was found to be not valid.
Findings
Areas of non-compliance were found, including failure to report a major incident within 24 hours to the regional licensing office as required.
Complaint Details
The complaint was investigated and found to be not valid due to insufficient evidence.
Deficiencies (1)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
Report Facts
Incident date: Dec 9, 2021
Notification delay: 61
Inspection Report
Deficiencies: 0
Dec 9, 2021
Visit Reason
The inspection was conducted as an unannounced non-mandated visit in reference to a facility self-reported incident.
Findings
The Licensing Inspectors interviewed residents and staff, reviewed resident records and additional documents for compliance, and found no violations cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 9, 2021
Visit Reason
Two representatives conducted an unannounced non-mandated complaint inspection initiated on 12/09/2021 and ended on 01/09/2022 to investigate a complaint regarding the facility.
Findings
The inspection included interviews with residents and staff and review of records. There was not enough evidence to support the allegation and the complaint was found to be not valid.
Complaint Details
Complaint was investigated and found to be not valid due to insufficient evidence.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the complaint inspection. |
| Kimberly Rodriguez | Licensing Inspector | Contact person for additional questions or concerns related to the inspection. |
Inspection Report
Renewal
Deficiencies: 4
Dec 9, 2021
Visit Reason
Two Licensing Inspectors conducted an unannounced, mandated renewal inspection to review resident and staff records, observe the facility physical plant, and review additional facility documentation for compliance.
Findings
The inspection identified multiple violations including failure to ensure annual tuberculosis evaluations, failure to complete annual uniform assessment instruments for residents, failure to have individualized service plans signed by residents or legal representatives, and facility physical plant issues such as broken floor tiles, broken cabinet doors, peeling and cracked cabinets, and chipped and peeling wall paint.
Deficiencies (4)
| Description |
|---|
| Failed to ensure subsequent tuberculosis evaluations were completed annually. |
| Failed to ensure all residents and applicants were assessed face to face using the uniform assessment instrument at least annually. |
| Failed to ensure the individualized service plan was signed and dated by the resident or legal representative. |
| Failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition; observed broken floor tile, broken cabinet door, peeling and cracked cabinets, and chipped and peeling wall paint. |
Inspection Report
Monitoring
Census: 90
Deficiencies: 0
Jun 10, 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 found no violations with applicable standards or law. Documentation including resident records, home health documentation, and training records were reviewed and found complete.
Report Facts
Resident records reviewed: 2
Inspection Report
Renewal
Census: 89
Deficiencies: 3
Feb 4, 2021
Visit Reason
A renewal inspection was initiated on February 4, 2021 and concluded on February 19, 2021 to assess compliance with applicable standards and laws for Indian River Assisted Living.
Findings
The inspection found non-compliance with standards related to menu documentation, failure to provide written responses to the resident council, and materially false statements on sworn statements by multiple staff members.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure menus for meals documented substitutions or additions on the posted menu. |
| Facility failed to provide a written response to the resident council regarding recommendations for resolution of problems or concerns. |
| Multiple staff made materially false statements on sworn statements or affirmations, constituting a Class 1 misdemeanor. |
Report Facts
Resident records reviewed: 7
Staff records reviewed: 5
Inspection dates: 4
Staff with false sworn statements: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 27, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding Resident Care and Related Services and timely securing of health care services for residents with respiratory medical conditions.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations related to failure to arrange specialized rehabilitative services and failure to ensure physician orders identified diagnoses or specific indications for medications.
Complaint Details
The complaint was related to allegations about Resident Care and Related Services and timely health care services for residents with respiratory conditions. The complaint was found not valid, but violations were issued based on investigation findings.
Deficiencies (2)
| Description |
|---|
| Facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by residents. |
| Facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. |
Report Facts
Inspection dates: 3
Resident hospital admission dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current inspector conducting the complaint investigation |
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