Inspection Reports for LiveWell at Birchwood Lake Estates

The Adult Care Licensure Section conducted an annual survey of Livewell Assisted Living on April 23, 2025, to assess compliance with applicable regulations including fire safety and tuberculosis testing requirements.

The facility failed to ensure compliance with local fire safety inspection requirements, as the most recent fire inspection report was dated 12/01/2023 and no inspection had been requested in the past year. Additionally, the facility failed to ensure one of three sampled residents had completed the required tuberculosis testing upon admission.

DHSR Construction Section conducted a Biennial Follow-up Survey to verify correction of previously cited deficiencies.

At the time of the survey, all of the previously cited deficiencies had been corrected, therefore no further action is required.

The Division of Health Service Regulation conducted a follow-up inspection to verify compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and the 2006 North Carolina State Building Code for a Family Care Home licensed for six ambulatory residents.

Multiple deficiencies were cited including missing sprinkler heads in closets, lack of smoke detectors in the old basketball court, missing heat detector in the attic, structural decay of the right side porch, open electrical sockets, use of extension cords, presence of space heaters in the garage, blocked breaker panel, unsecured propane tank, and lack of a carbon monoxide detector near the propane water heater.

The Division of Health Service Regulation conducted a follow-up survey to verify compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and the 2006 North Carolina State Building Code for a Family Care Home licensed for six ambulatory residents.

Multiple deficiencies were cited including unauthorized construction without plan approval, privacy issues in bedroom #1, missing sanitation and fire safety reports, insufficient bathrooms due to ongoing construction, missing corridor night lights, malfunctioning fire alarm and stove hood light, various building maintenance issues such as missing hot water tank drain line, attic access blocked, loose toilet, moss and debris on roofs, unsafe sidewalks, exposed live wires, disconnected ductwork, improperly oriented evacuation plans, dirty HVAC filters, non-functioning emergency lights, inadequate fire audible devices, missing sprinkler head removal tool, missing smoke detectors, improper storage of flammable items, and missing sprinkler head in a closet.

The Adult Care Licensure Section conducted an annual survey of Livewell Assisted Living from November 20, 2018 through November 21, 2018 to assess compliance with regulatory requirements.

The facility was found deficient in staff training on diabetic care, failure to provide a matching therapeutic diet menu for a resident with a high fiber diet order, failure to serve therapeutic diets as ordered, and failure to administer medications according to licensed practitioner orders for one resident.

The Adult Care Licensure Section conducted a follow-up survey to assess compliance with evacuation capabilities and fire safety regulations at Livewell Assisted Living.

The facility failed to assure that residents' evacuation capabilities matched the evacuation capability listed on the home's license for 3 residents with cognitive and/or physical impairments. The sprinkler system installation was in progress but not yet operational. Staffing was maintained at a 1:1 ratio to mitigate risks until full compliance is achieved.

The Adult Care Licensure Section and the Orange County Department of Social Services conducted an annual survey of Livewell Assisted Living on January 3, 2017.

The facility was found to have residents whose evacuation capabilities did not match the licensed evacuation capability, with 4 of 4 residents having cognitive and/or physical impairments preventing independent evacuation. Additionally, the facility failed to conduct the required number of fire drills in 2016 according to North Carolina Fire Code, and there was a failure to maintain adequate staffing to safely evacuate residents.

Biennial survey conducted by the DHSR Construction Section to assess compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and the 2006 North Carolina State Building Code for Residential Care Homes.

The facility was found to have multiple deficiencies including non-compliance with building code requirements related to resident ambulatory status and licensed capacity, lack of mechanical ventilation in a bathroom, incorrect fire evacuation plan orientation, and maintenance issues such as peeling sink cabinet finish and an open electrical outlet box.