Inspection Reports for Living Well Assisted Living
2600 Shorehaven Dr, Virginia Beach, VA 23454, USA, VA, 23454
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 6
Deficiencies: 3
Mar 27, 2025
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with several standards related to resident admission documentation, physical examination records, and annual review of resident rights and responsibilities. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| The facility administrator did not ensure written assurance was provided to the resident that the facility has the appropriate license to meet his care needs at admission; the signed Written Assurance was missing from Resident #3's record. |
| The facility did not ensure a complete physical examination by an independent physician within 30 days preceding admission; page 2 of Resident #3's physical exam was missing. |
| The facility did not ensure the rights and responsibilities of residents were reviewed annually and documented; Resident #3's 2025 signed Rights and Responsibilities form was missing. |
Report Facts
Number of residents present: 6
Number of resident records reviewed: 4
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Number of observations by licensing inspector: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #2 | Confirmed missing documentation in Resident #3's record |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 3
Oct 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/25/2024 regarding allegations related to Admission, Retention and Discharge of Residents and Resident Accommodations and Related Provisions.
Findings
The investigation supported the allegations of non-compliance with applicable standards and laws, resulting in violations issued. Deficiencies were found related to failure to ensure written assurance prior to admission, lack of signed orientation forms, and inadequate observation and care planning for residents with specific needs.
Complaint Details
Complaint related to Admission, Retention and Discharge of Residents and Resident Accommodations. The evidence supported the allegations and violations were issued.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure the UAI prior to admission; written assurance was not signed by resident or legal representative. |
| Facility did not provide signed orientation forms for new residents and legal representatives. |
| Facility did not regularly observe residents for changes in physical, mental, emotional, and social functioning; care plans lacked hospice care plan, falls risk, and oxygen therapy outcomes. |
Report Facts
Number of residents present: 5
Number of resident records reviewed: 2
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and is the contact for the report |
| Staff 1 | Reviewed resident records and acknowledged deficiencies |
Inspection Report
Renewal
Census: 6
Deficiencies: 14
Mar 19, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Living Well Assisted Living facility on March 19 and 20, 2024, to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations related to physical examinations, approval of assessments, health care oversight, activity scheduling, diet orders, dietary oversight, medication cart security, supervision of medication aides, medication reviews, oxygen use, fire and emergency drills, first aid kit checks, emergency exercise participation, and background checks. Plans of correction were implemented or scheduled for all cited violations.
Deficiencies (14)
| Description |
|---|
| Failed to ensure a physical examination by an independent physician was completed within 30 days preceding admission and contained required items. |
| Failed to ensure for private pay individuals, the administrator or designated representative approved and signed the completed UAI. |
| Failed to retain a licensed health care professional to provide on-site health care oversight within compliance to the standard. |
| Failed to ensure the current month's schedule of activities included the type and hour of the activity. |
| Failed to ensure prescribed diets were prepared and served according to physician's orders. |
| Failed to ensure dietary oversight was conducted every six months for special diets by a dietitian or nutritionist. |
| Failed to ensure the medication cart was locked and keys kept on the person responsible for medication administration. |
| Failed to ensure medication aides are supervised by a qualified individual. |
| Failed to ensure medication reviews were conducted every six months by a licensed health care professional. |
| Failed to ensure only portable oxygen sources were used by residents outside their rooms; long plastic tether lines were used. |
| Failed to ensure fire and emergency evacuation drills were conducted with required frequency and participation. |
| Failed to ensure first aid kits were checked monthly for completeness and expiration dates. |
| Failed to document staff participation in emergency practice exercises at least every six months. |
| Failed to ensure criminal history record reports were current within 90 days of employment. |
Report Facts
Number of residents present: 6
Number of resident records reviewed: 3
Number of staff records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
| Lanesha Allen | Current Inspector | Inspector on-site during the inspection |
| Staff #1 | Confirmed lack of qualified medication aide supervisor and last medication review date | |
| Staff #2 | Unable to provide documentation of emergency exercise participation | |
| Staff #3 | Criminal history record report was outdated; staff member terminated |
Inspection Report
Monitoring
Census: 6
Deficiencies: 4
Dec 28, 2023
Visit Reason
The inspection was a monitoring visit conducted on December 28, 2023, following a self-reported incident received on December 19, 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 multiple violations issued related to administrator coverage lapse, fall risk assessment, resident safety, and door security. The facility failed to employ a new administrator promptly, update fall risk ratings, ensure resident safety, and maintain proper door security.
Deficiencies (4)
| Description |
|---|
| Facility failed to immediately employ a new administrator or appoint a qualified acting administrator causing a lapse in administrator coverage. |
| Facility failed to ensure the fall risk rating was reviewed and updated at least annually, when the condition of the resident changes, and after a fall. |
| Facility failed to assume general responsibility for the health, safety, and well-being of the residents, resulting in a resident wheeling out of the front door, falling, and sustaining injuries. |
| Facility failed to ensure doors leading to the outside were not locked or secured from the inside in any manner that amounts to a lock. |
Report Facts
Number of residents present: 6
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Date of resident fall: Dec 18, 2023
Date of last fall risk rating before incident: Dec 5, 2022
Date fall risk rating completed: Dec 28, 2023
Date new administrator started: Jan 2, 2024
Inspection Report
Monitoring
Census: 4
Deficiencies: 3
Jul 7, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care, background checks, and criminal history record requirements for the assisted living facility.
Findings
The inspection found non-compliance with medication administration timing, adherence to physician orders, and background check documentation for temporary agency staff. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure when utilizing temporary agencies for substitute staff, a letter from the agency containing required information was maintained. |
Report Facts
Number of residents present: 4
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of medications not administered: 7
Number of doses of Midodrine administered: 4
Inspection Report
Renewal
Census: 5
Deficiencies: 20
Mar 23, 2023
Visit Reason
The inspection was a renewal inspection conducted on March 22 and March 30, 2023, to assess compliance with applicable standards and laws for Living Well Assisted Living.
Findings
The inspection identified multiple violations including failure to provide required staff training, unsafe access to harmful materials, failure to report major incidents timely, incomplete staff records, inadequate medication management, and failure to maintain confidentiality of criminal history reports. Plans of correction were proposed for each violation.
Deficiencies (20)
| Description |
|---|
| Facility failed to ensure direct care staff received six hours of training in working with individuals with cognitive impairment within four months of employment. |
| Facility failed to ensure harmful materials were inaccessible to residents with serious cognitive impairment without staff supervision. |
| Facility failed to report a major incident affecting a resident to the regional licensing office within 24 hours. |
| Facility failed to maintain personal and social data on staff including verification of receipt of current job description. |
| Facility failed to maintain required health information in staff records, including TB risk assessments. |
| Facility failed to ensure direct care staff maintained current certification in first aid. |
| Facility failed to post the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to utilize a method of written communication to keep direct care staff informed of significant happenings or problems. |
| Facility failed to provide written assurance to a resident or legal representative documenting appropriate licensing at admission. |
| Facility failed to ensure administrator or designated representative approved and signed the UAI for private pay individuals. |
| Facility failed to develop a preliminary plan of care for a resident within seven days prior to admission. |
| Facility failed to annually review residents' rights and responsibilities with staff. |
| Facility failed to keep all resident records in a locked area. |
| Facility failed to ensure a current picture or narrative physical description of each resident was maintained. |
| Facility failed to ensure accurate counts of controlled substances when medication administration staff changed. |
| Facility failed to ensure physician or prescriber orders identified diagnosis or indications for medications. |
| Facility failed to ensure medication cart was locked and keys kept on person responsible for medication administration. |
| Facility failed to ensure MAR included required items such as date prescribed, diagnosis, and staff signatures. |
| Facility failed to keep criminal history record reports confidential and completed by authorized personnel. |
| Facility failed to maintain letters from temporary agencies for substitute staff background checks. |
Report Facts
Number of residents present: 5
Number of resident records reviewed: 4
Number of staff records reviewed: 5
Number of physician orders: 11
Frequency of shelf checks: 3
Audit period: 3
Inspection Report
Monitoring
Census: 4
Deficiencies: 12
Dec 29, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at Living Well Assisted Living facility.
Findings
The inspection found multiple violations related to resident records, mental health screening, medication management, staff hiring procedures, and facility maintenance. The licensee was given a violation notice and opportunity to submit a plan of correction.
Deficiencies (12)
| Description |
|---|
| Failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative. |
| Failed to provide written assurance to residents or legal representatives documenting the facility's appropriate license upon receiving licensure. |
| Failed to ensure mental health screening was conducted prior to admission when indicated by behaviors within the previous six months. |
| Failed to ascertain and document whether a potential resident was a registered sex offender prior to admission. |
| Failed to provide orientation for new residents and their legal representatives including emergency procedures and use of call system. |
| Failed to ensure individualized service plans were signed and dated by residents or their legal representatives. |
| Failed to implement written plan for medication management to prevent use of outdated medications; expired medication found. |
| Failed to ensure no medication, diet, or treatment was started, changed, or discontinued without a valid prescriber order. |
| Failed to ensure medications were administered within one hour before or after the facility's standard dosing schedule. |
| Failed to ensure medications were administered in accordance with physician's or prescriber's instructions. |
| Failed to ensure common face/hand washing sinks had paper towels or air dryers for hand washing. |
| Failed to obtain a criminal history record report on or prior to the 30th day of hire for each employee. |
Report Facts
Number of residents present: 4
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 3
Number of medication administration late or undocumented events: 30
Number of staff missing criminal history reports: 2
Inspection Report
Original Licensing
Census: 3
Deficiencies: 0
Nov 2, 2022
Visit Reason
Initial licensing inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed emergency preparedness and resident care provisions.
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