Inspection Reports for
Living Waters Senior Care
379 North Main Street, TIMBERVILLE, VA, 22853
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Virginia average
Virginia average: 9.1 deficiencies/year
Deficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
33 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Monitoring
Census: 33
Deficiencies: 1
Date: Sep 12, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-08-19 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication administration, specifically the failure to ensure physician's or prescriber's oral orders were reviewed and signed within 14 days. Violations were issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
The facility failed to ensure physician's or other prescriber's oral orders were reviewed and signed by a physician or other prescriber within 14 days.
Report Facts
Number of residents present: 33
Number of resident records reviewed: 3
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 30
Deficiencies: 13
Date: Jun 26, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for Living Waters Senior Care.
Findings
The inspection identified multiple violations related to staff orientation and training, tuberculosis risk assessments, resident admission documentation, individualized service plans, medication administration licensure, emergency preparedness, fire drills, first aid kit completeness, resident emergency exercises, and employee criminal background checks. Plans of correction were initiated for all deficiencies.
Deficiencies (13)
Failed to ensure required orientation and training occurred within the first seven working days of employment.
Failed to ensure each staff person submitted tuberculosis risk assessment results prior to or within seven days of first work day.
Failed to provide written assurance to resident that facility had appropriate license at time of admission.
Failed to ensure admission physical examination and report contained all required information.
Failed to ascertain and document whether potential resident was a registered sex offender prior to admission.
Failed to ensure written agreement or acknowledgment of notification was signed and dated by resident or legal representative and licensee at or prior to admission.
Failed to ensure comprehensive Individualized Service Plans contained all assessed needs.
Failed to ensure staff administering medication were licensed or registered with Virginia Board of Nursing.
Failed to implement orientation and semi-annual review on emergency preparedness and response plan for all staff.
Failed to ensure fire and emergency evacuation drill frequency and participation met Virginia Statewide Fire Prevention Code.
Failed to ensure a complete first aid kit was on hand in each building containing all required items.
Failed to ensure all staff participated in six-month resident emergency exercises.
Failed to obtain criminal history record report on or prior to 30th day of employment for each employee.
Report Facts
Residents present: 30
Resident records reviewed: 4
Staff records reviewed: 6
Resident interviews conducted: 3
Staff interviews conducted: 4
Medications administered: 1815
Residents receiving medications from staff 3: 27
Fire drills documented: 6
New hires since last inspection: 9
Employees with delayed criminal history reports: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 3 | Medication Aide | Named in deficiency for administering medications without proper licensure or registration |
| Staff 4 | Named in deficiencies related to orientation, tuberculosis risk assessment, and staff records | |
| Staff 1 | Interviewed staff providing information on orientation, tuberculosis risk assessment, and medication licensure | |
| Staff 2 | Interviewed staff providing information on resident assurances, physical exams, sex offender searches, resident agreements, ISPs, fire drills, first aid kit, emergency exercises, and criminal history reports |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: May 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-30 regarding allegations in the areas of Resident Care and Related Services, Admission Retention and Discharge of Residents, staffing, supervision, and buildings and grounds.
Complaint Details
Complaint related inspection triggered by allegations in Resident Care and Related Services, Admission Retention and Discharge of Residents, staffing, supervision, and buildings and grounds. The evidence gathered did not support the allegations of non-compliance.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified regarding failure to ascertain prior to admission whether a potential resident was a registered sex offender.
Deficiencies (1)
The facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender.
Report Facts
Number of residents present: 31
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-24 regarding allegations related to building and grounds conditions at the facility.
Complaint Details
The complaint investigation was substantiated in part, with violations found related to building and grounds standards 22VAC40-73-860-D and 22VAC40-73-870-A. Some allegations were not supported.
Findings
The investigation supported some but not all allegations, identifying non-compliance with standards related to building maintenance, door and window conditions, and storage of hazardous materials. Violations were found regarding doors not closing effectively, missing window screens, unsecured cleaning supplies, and poor maintenance of building interiors.
Deficiencies (3)
Facility failed to ensure that all doors closed effectively, and any operable window was effectively screened.
Facility failed to store cleaning supplies and other hazardous materials in a locked area.
Facility failed to ensure the interior of all buildings were maintained in good repair and kept clean.
Report Facts
Residents present: 36
Operational windows without screens: 15
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Apr 3, 2025
Visit Reason
The inspection was conducted due to a complaint received by the VDSS Division of Licensing on April 3, 2025, regarding allegations of a resident-to-resident altercation and reporting issues.
Complaint Details
The complaint alleged that resident 1 pushed resident 2 on 3/20/2025 and again on 3/30/2025. The evidence gathered did not support the allegation(s) of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to report major incidents within 24 hours and failure to update individualized service plans as required.
Deficiencies (2)
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 any resident.
Facility failed to update and review individualized service plans at least once every 12 months and as needed for significant changes in a resident's condition.
Report Facts
Number of residents present: 36
Incident dates: 2
Dates of aggressive behavior: 14
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 6
Date: Mar 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-05 regarding allegations in the areas of resident care and related services, building and grounds, and protection of adults and reporting.
Complaint Details
Complaint was received on 2025-03-05 regarding resident care and related services, building and grounds, and protection of adults and reporting. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, several violations unrelated to the complaint were identified, including failure to notify the licensing office of an administrator change, lack of a written staffing plan, incomplete work schedules, locked exit doors requiring a code, medication administration errors, and maintenance issues with kitchen equipment and cabinetry.
Deficiencies (6)
Facility failed to notify the department's regional licensing office in writing within 14 days of a change in facility administrator.
Facility failed to maintain a written staffing plan specifying direct care staff requirements related to resident acuity and needs.
Facility failed to maintain a written work schedule indicating who is in charge at any given time.
Facility failed to ensure doors leading to the outside were not locked or secured from the inside in a manner amounting to a lock.
Facility failed to ensure medications were not administered earlier than one hour before or later than one hour after the standard dosing schedule.
Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition.
Report Facts
Residents present: 38
Resident records reviewed: 1
Staff records reviewed: 3
Resident interviews: 4
Staff interviews: 5
Medications administered early: 120
Residents affected by medication error: 28
Residents unable to exit without assistance: 8
Residents assessed for risk: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gale | Licensing Inspector | Contact person for questions about the inspection. |
| Angela N Via | Licensing Inspector | Inspector on-site during the inspection. |
| Staff 1 | Interviewed regarding staffing plan, work schedule, and door lock issues. | |
| Staff 2 | Acting administrator and involved in medication administration errors and door lock issues. | |
| Staff 3 | Provided email confirming administrator change and lack of notification. | |
| Staff 4 | Former administrator whose resignation was not timely reported. |
Inspection Report
Renewal
Census: 30
Deficiencies: 5
Date: Jul 25, 2024
Visit Reason
The inspection was a renewal inspection conducted on July 25 and July 26, 2024, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to address mental health needs in Individual Service Plans, failure to update service plans annually, lack of snacks availability for residents, failure to include snacks in the daily menu per USDA guidance, and maintenance issues with outdoor furniture and gazebo access. Plans of correction were proposed for each violation.
Deficiencies (5)
Facility failed to address on Individual Service Plans how identified mental health needs would be provided.
Facility failed to review and update Individualized service plan on an annual basis.
Facility failed to have snacks available at all times for all residents.
Facility failed to ensure the daily menu included snacks based on USDA guidance.
Facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Report Facts
Number of residents present: 30
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of resident interviews: 3
Number of staff interviews: 4
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-05-22 regarding allegations related to building and grounds conditions at the facility.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, including observations and resident interviews confirming lack of toilet paper and paper towels.
Findings
The investigation found violations related to inadequate supply of toilet tissue and lack of paper towels or air dryers in common handwashing sinks. These deficiencies were confirmed by direct observation and resident interviews.
Deficiencies (2)
Facility failed to ensure there was an adequate supply of toilet tissue accessible to each commode.
Facility failed to ensure that common hand washing sinks have paper towels or an air dryer for handwashing.
Inspection Report
Monitoring
Census: 31
Deficiencies: 20
Date: Jun 17, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 17 and 18, 2024, to review compliance with applicable standards and laws for an assisted living facility.
Findings
The inspection found multiple violations including inadequate staff training hours, outdated CPR certification lists, failure to post the current person in charge, lack of sex offender registration and notification procedures, incomplete resident orientation documentation, deficient individualized service plans, failure to maintain resident records securely, missing posted menus, medication management issues, facility maintenance problems, inadequate emergency preparedness reviews, incomplete fire drill records, insufficient first aid kit supplies, and missing criminal history reports for employees.
Deficiencies (20)
Facility failed to ensure all direct care staff attend at least 14 hours of training annually.
Facility failed to keep an up-to-date list of staff with current CPR certifications.
Facility failed to post the name of the current on-site person in charge in a conspicuous place.
Facility failed to register with the Department of State Police to receive sex offender notifications.
Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.
Facility failed to annually inform residents or their legal representatives about sex offender information.
Facility failed to ensure orientation acknowledgment was signed and dated by residents or legal representatives.
Facility failed to review and update individualized service plans at least annually and as needed.
Facility failed to ensure annual review of resident rights with staff.
Facility failed to keep resident records current, retained at the facility, and in a locked area.
Facility failed to post the weekly menu in an area conspicuous to residents.
Facility failed to implement a written plan for medication management to ensure timely filling and refilling of prescriptions.
Facility failed to ensure PRN medications were available, properly labeled, and stored.
Facility failed to maintain the interior and exterior of buildings in good repair and free of rubbish.
Facility failed to maintain a temperature of at least 72 degrees in resident areas.
Facility failed to ensure semi-annual review of emergency preparedness and response plans.
Facility failed to ensure fire and emergency evacuation plan showed all required elements.
Facility failed to provide documentation of fire drills for several months in 2023.
Facility failed to ensure the first aid kit included all required items.
Facility failed to obtain criminal history reports prior to the 30th day of employment for some staff.
Report Facts
Number of residents present: 31
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 2
Number of interviews with staff: 3
Training hours completed by Staff 3: 9.53
Missing items in first aid kit: 12
Fire drill months missing documentation: 5
Inspection Report
Renewal
Census: 33
Deficiencies: 1
Date: Jul 30, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license to assess compliance with applicable standards and laws.
Findings
The facility was generally clean with required postings and completed emergency drills and outside inspections. However, non-compliance was found related to missing items in service plans for all six resident files reviewed, which did not match current identified needs.
Deficiencies (1)
All six resident files had items missing from the service plans matching the current identified needs based on the uniform assessment instrument or physical/dietary paperwork, including special diets, mechanical supports, mental health supports, and level of assistance.
Report Facts
Residents present: 33
Resident records reviewed: 6
Staff records reviewed: 4
Resident interviews: 2
Staff interviews: 3
Inspection Report
Renewal
Census: 23
Deficiencies: 1
Date: Jul 13, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for Living Waters Senior Care.
Findings
The inspection found non-compliance with one applicable standard related to medication administration records missing diagnoses for multiple medications for three residents.
Deficiencies (1)
Multiple medications for three residents were missing a diagnosis on the medication administration records and corresponding orders.
Report Facts
Residents reviewed: 3
Staff records reviewed: 3
Additional background checks reviewed: 9
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