VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Living Well Assisted Living
2600 Shorehaven Drive
Virginia beach, VA 23454
(757) 690-2744

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: July 7, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/07/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-C
Description:	Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The June 2023 MAR for Resident #1 indicates the resident was not administered their 8:00 PM medications (7 total) on 06/18/2023.
Plan of Correction:	All RMAs will receive an in-service on recording medication passes. The owner or designee will do a regular audit to insure medications are recorded.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident #2?s blood pressure check order reads the following: ?check blood pressure while seated 3 times daily with meals for monitoring. If Blood Pressure <105/70, see as needed Midodrine Order.? Upon review of the June 2023 MAR, Resident #2 received 1 dose of Midodrine on 6/15/23, 6/17/23, 6/22/23, and 6/29/23. However, Resident #2?s BP met the parameters of <105/70 to receive Midodrine on the following days: 1 dose on 6/15/23, 1 dose on 6/23/23, 1 dose on 6/26/23, 2 doses on 6/29/23, and 1 dose on 6/30/23.
Plan of Correction:	Owner will have NP clarify the order when Midrodine is to be administered. An in-service for all RMAs will occur after the order is changed.
Standard #:	22VAC40-90-50-A
Description:	Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency containing information listed in the standard. Evidence: 1. Staff #4, Staff #5, and Staff #6 did not have a statement verifying that the criminal history record report by the Virginia State Police has been obtained within 30 days of employment, is on file at the temporary agency, and does not contain barrier crimes.
Plan of Correction:	KARE staff will not be allowed to work unless another staff member who has a completed a background check is available to supervise them. The first time a KARE staff member comes to work, an online background check will be done.