26
Inspections
On record
14
With violations
Visits that cited something
12
Clean visits
Nothing cited
37
Violations cited
Individual findings
25
Standards cited
Distinct rules
13
Complaint visits
Prompted by a complaint
The Ridge at Sterling was inspected 26 times between March 18, 2021 and May 6, 2026 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 37 violations under 25 distinct standards. 13 inspections were prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
VDSS publishes inspections on a rolling window. 24 of these 26 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
11/03/2026
Administrator
Patricia Salao
Licensing inspector
Marshall Massenberg
Inspector phone
(804) 543-5188
Approved for
Assisted Living · Non-Ambulatory
Inspection History
26Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
May 6, 2026Complaint survey
Inspection dates
05/06/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS63.2 FACILITIES AND PROGRAMS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/6/26 (2:30 PM - 5:20 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by the Fairfax Licensing Office on 3/11/26 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents.
Number of residents present at the facility at the beginning of the inspection: 65
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: One
Number of staff records reviewed: None
Number of interviews conducted with residents: None
Number of interviews conducted with staff: Four
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-430-H-1
Based on record review and interview, the facility did not ensure that a discharge statement is provided, at the time of discharge, to the resident, and, as appropriate, his legal representative.
A copy of the written statement shall be retained in the resident's record.
Evidence
- Resident #1's record was observed during the inspection. Resident #1's record contained a progress note, dated 3/13/26, indicating that the resident moved out on that date. No discharge statement was provided, during the inspection. Facility staff confirmed that no discharge statement was present in Resident #1's record.
Plan of correction
Not published by VDSS.
May 6, 2026Complaint survey
Inspection dates
05/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 FACILITIES AND PROGRAMS
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/6//26 (2:30PM - 5:20 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by the Fairfax Licensing Office on 3/23/26 in the area of: Resident Care and Related Services.
Number of resident records reviewed: One
Staff Records reviewed: None
Number of interviews conducted with residents: None
Number of interviews conducted with staff: Three
Observations by licensing inspector: N/A
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 9, 2026Complaint survey
Inspection dates
03/09/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/9/26 (3:40 PM - 5:25 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by the Fairfax Licensing Office on 3/3/26 regarding allegations in the area(s) of: Administration and Administrative Services; Personnel; Staffing and Supervision; Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 61
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Three
Number of staff records reviewed: One
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Three
Observations by licensing inspector: Facility Schedules
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-290-A
Based on observation and interview, the facility did not maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
- Facility schedules for February and March were observed during the inspection. Staff #2 reported working at the facility in February and March 2026. Staff #2 was not documented on the observed schedules for February or March 2026. The observed schedules did not indicate who would be considered in charge on each shift.
Plan of correction
Administrator's work schedule has been created and placed at the front desk and provided to all department heads.
This positions schedule has been added to the main staffing schedule moving forward to ensure all persons are aware to their schedule and availability.
22VAC40-73-150-B-6
Based on documentation, the facility failed to ensure that an acting administrator does not operate the facility for longer than 150 days.
Evidence
- Facility documentation states that Staff #1 became the facility's acting administrator on March 28, 2025. Staff #2 was reported to be the facility's licensed administrator on 2/4/26. Staff #1 served as an acting administrator, without being licensed as an assisted living facility administrator or nursing home. administrator by the Virginia Board of Long-Term Care Administrators, for a period of longer than 150 days.
Plan of correction
Person that failed to achieve licensure was removed from position and a licensed person put in place.
The company will only employ administrators that have already achieved licensure moving forward.
March 9, 2026Inspection
Inspection dates
03/09/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 FACILITIES AND PROGRAMS
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: 3/9/26 (3:40 PM - 5:25 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by the Fairfax Licensing Office on 2/9/26 in the area of: Resident Care and Related Services.
Number of resident records reviewed: Three
Staff Records reviewed: One
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Three
Observations by licensing inspector: N/A
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 9, 2026Complaint survey
Inspection dates
03/09/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 FACILITIES AND PROGRAMS
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/9/26 (3:40 PM - 5:25 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by the Fairfax Licensing Office on 2/18/2026 in the area of: Resident Care and Related Services.
Number of resident records reviewed: Three
Staff Records reviewed: One
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Three
Observations by licensing inspector: N/A
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
December 15, 2025Complaint survey
Inspection dates
12/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/15/25 (2:30 PM - 4:00 PM).
A complaint was received by the Fairfax Licensing Office on 11/21/25 regarding allegations in the area(s) of: Resident Care and Related Services; Resident Accommodations and Related Provisions
Number of residents present at the facility at the beginning of the inspection: 64
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Two
Number of interviews conducted with residents: One
Number of interviews conducted with staff: One
Additional Comments/Discussion:
An exit meeting was conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Accommodations and Related Provisions.
A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
22VAC40-73-750-B
Based on observation, the facility did not ensure that all of the required items are present in each resident room.
Evidence
- Resident #1's room was observed during the inspection. Resident #1's room did not contain a bed. No documentation was included in Resident #1's record to indicate that he did not want to have a bed in his room. No documentation was provided, during the inspection, to confirm in writing that Resident #1 did not want a bed in his room.
Plan of correction
Corrective Action Taken for the Affected Resident
A bed was immediately placed in Resident #1's room upon identification of the deficiency OR
If Resident #1 declined use of a bed, written documentation was obtained from the resident and/or responsible party confirming the resident's preference, and this documentation was placed in the resident's record.
The Resident Services Director (RSD) verified completion and documentation.
Systemic Corrective Actions to Prevent Recurrence
Documentation Requirement for Declined Furnishings
If a resident declines any required furnishing (including a bed), the facility will:
Obtain written acknowledgment from the resident and/or responsible party
Place documentation in the resident’s permanent record
Update the service plan to reflect the resident's preference and safety considerations
Staff Education
The Executive Director and Resident Services Director provided re-education to admissions, nursing, and maintenance staff on:
22VAC40-73-750-B requirements
Documentation standards for resident preferences
Education completion has been documented.
Ongoing Monitoring
The Executive Director or designee will conduct periodic room reviews to ensure compliance with furnishing and documentation requirements.
Any identified concerns will be addressed immediately.
Responsible Staff
Executive Director
Resident Services Director
Admissions
Maintenance Director
November 24, 2025Inspection
Inspection dates
11/24/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS
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: 11/24/25 (5:20 PM - 5:40 PM)
A self-reported incident was received by VDSS Division of Licensing on 11/3/25 regarding allegations in the area(s) of: Building and Grounds
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: None
Number of interviews conducted with residents: None
Number of interviews conducted with staff: One
Observations by licensing inspector: Facility documentation
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 3, 2025Complaint survey
Inspection dates
11/03/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/3/25 (4:20 PM - 5:10 PM).
A complaint was received by the Fairfax Licensing Office on 10/27/2025 in the area(s) of: Resident Accommodations and Related Provisions and Buildings and Grounds.
Number of residents present at the facility at the beginning of the inspection: 66
Number of resident records reviewed: Two
Number of interviews conducted with residents: One
Number of interviews conducted with staff: One
Observations by licensing inspector: Building and Grounds
The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Marshall Massenberg, Licensing Inspector (804) 543-5188 or by email at Marshall.x.Massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
October 24, 2025Inspection
Inspection dates
10/24/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/24/25 (8:15 AM - 3:35 PM)
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: 63
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 6
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Observations by licensing inspector: Meals, medication administration, activities, criminal background checks
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on documentation, the facility did not ensure that the medication management plan was implemented to ensure that each resident's prescription medications and any over-the-counter drugs are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- Resident #1's morning medication administration was observed during the inspection. Resident #1 did not receive his Fludrocortisone (ordered 9/27/25) during the morning medication administration. Resident #1's medication administration record (MAR) stated that Resident #1 did not receive his Fludrocortisone on 10/21/25, 10/23/25, or 10/24/25 because the facility was "awaiting medication from pharmacy/family."
Plan of correction
The medication management plan was reviewed with all Med Techs and licensed staff. Any deviations identified during the inspection were corrected immediately and documentation updated accordingly.
The Medication Management Plan has been re-reviewed by the Administrator and Nurse. A mandatory competency review and refresher education on medication pass procedures will be provided to all staff responsible for medication administration. The Medication Management Plan has been posted in the medication room and included in new staff onboarding.
The Nurse or Designee will complete weekly medication administration audits for 8 weeks, then monthly thereafter for 3 months. Any variances will be promptly retrained and documented. Findings will be reviewed during monthly QA meetings.
22VAC40-73-150-B-6
Based on documentation, the facility failed to ensure that an acting administrator does not operate the facility for longer than 150 days.
Evidence
- Facility documentation states that Staff #4 became the facility's acting administrator on March 28, 2025. At the time of the inspection, Staff #4 was operating the facility as an acting administrator for more than 150 days.
Plan of correction
The current Administrator has been officially appointed and documentation has been submitted to the licensing office. All required administrator credentials are on file.
In the event of future leadership transitions, the facility will notify VDSS within required timeframes and ensure that acting appointments do not exceed regulatory limits. Regional Director of Operations will be used to support coverage if needed.
Regional Director of Operations and Administrator will review license status and credential tracking quarterly to ensure compliance.
22VAC40-73-210-B
Based on documentation and interview, the facility did not ensure that each direct care staff member attends at least 18 hours of training annually.
Evidence
- The record for Staff #1, hired 12/6/23 as a PCA, was reviewed during the inspection. Staff #1's record included one training (Medication Basics for Caregivers) that was completed within the review period (12/6/23 - 12/6/24). Collateral #1 reported that Medication Basics for Caregivers is listed as a one-hour course in Virginia. No documentation was provided, during the inspection, to indicate that Staff #1 completed the required 18 hours of annual training within the review period.
Plan of correction
Training records were reviewed and staff missing hours were scheduled to complete required modules. Documentation of completion is being filed in personnel records.
A training tracking calendar has been implemented to ensure staff remain current. New hires will be assigned training hours during orientation and monitored at 30/60/90 days.
The Administrator or Designee will review training completion progress monthly for three months and report compliance during QA meetings.
22VAC40-73-650-E
Based on record review, the facility did not ensure that the resident record contains the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order.
Evidence
- Resident #2's insulin administration was observed during the inspection. Resident #2's insulin order, dated 9/10/25, was not present in the resident record, at the time of the record review.
Plan of correction
All resident records were reviewed. Missing physician orders were requested from providers and filed in the residents’ records immediately.
A chart review process will occur for all new orders to ensure documentation is scanned/filed at the time of receipt. The Nurse will reconcile orders during routine medication change reviews.
The Nurse or Designee will complete monthly chart for three months audits to ensure physician orders are present, accurate, and current. Results will be reviewed during QA.
September 4, 2025Complaint survey
Inspection dates
09/04/2025, 09/11/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/4/25 (9:00 AM - 1:10 PM), 9/11/25 (2:45 PM - 5:00 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 8/11/25 regarding allegations in the area(s) of: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 58
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Five
Number of interviews conducted with residents: Five
Number of interviews conducted with staff: Four
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some the allegation of non-compliance in the area(s) of: Resident Care and Related Services
A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on observation and documentation, the facility did not ensure that medications are administered in accordance with the physician’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
- Resident #2's MAR states that her Metoprolol should be held if her pulse is less than 55 or if her systolic blood pressure (SBP) is less than 110. On 8/29/25 (10 AM administration), Resident #2's Metoprolol was documented as administered when her systolic blood pressure was 109. Resident #4's insulin administration was observed during the inspection. Resident #4's MAR calls for her to receive 10 units of Novolog, plus additional 1 unit for every 50mg/dl above the target BG of 150. Resident #4 was administered 11 units of Novolog when her BG was 164. Resident #4's MAR indicates that her Carvedilol should be held if her Systolic BP (SBP) is less than 130 on dialysis days (Mon, Wed, Fri). Resident #4's Carvedilol was administered on 8/20/25 (7 PM administration - SBP 121) and 8/27/25 (7 PM administration - SBP 117), when her SBP was less than 130.
Plan of correction
- Resident #2: Med Tech assigned refresher training through pharmacy.
- Resident #4: Quickmar corrected to include both blood sugar values and insulin units administered.
- Carvedilol error addressed with Med Tech refresher course on cardiac medications and double-check procedures.
- All Med Techs to attend pharmacy-led refresher on insulin administration and Quickmar documentation.
- RSD to audit diabetic MARs daily x14 days, then weekly x60 days.
- Random audit of high-risk medications (e.g., Carvedilol) weekly x60 days.
22VAC40-73-680-I
Based on documentation, the facility did not ensure that all of the required information is included on the medication administration record (MAR).
Evidence
- Resident #4 receives Novolog with a sliding scale, based upon her blood glucose reading. Resident #4's MAR documented her blood glucose reading for each administration of her Novolog, but the MAR did not document how much Novolog was administered to Resident #4. Resident #5 receives insulin with a sliding scale, based upon his blood glucose reading. Resident #5's MAR documented his blood glucose reading for each administration of his sliding scale insulin, but his MAR did not document how much insulin was administered to Resident #5 after 8/16/25.
Plan of correction
- Quickmar updated for both residents to document both blood sugar results and insulin administered.
- Med Tech refresher training scheduled for all staff on MAR documentation requirements.
- RSD will conduct random weekly MAR audits for all diabetic residents for 60 days.
- All documentation errors to be reviewed at monthly RSD/ED meetings.
22VAC40-73-680-M
Based on observation and interview, the facility did not ensure that all PRN medications are available and properly stored at the facility.
Evidence
- PRN enema, ordered 12/24/24 for Resident #4, was not present at the time of the medication cart inspection. Facility staff confirmed that the medication was not present, at the time of the medication cart inspection. PRN Glutose gel and PRN Glucagon emergency kit, ordered 8/11/24 for Resident #5, were not present at the time of the medication cart inspection. PRN Oxycodone, ordered 9/8/24 for Resident #5, was observed to be expired at the time of the medication cart inspection. The expiration date listed on the PRN Oxycodone was 9/8/25. Facility staff confirmed that the PRN Oxycodone was expired and that the PRN Glutose gel and Glucagon emergency kit were not present, at the time of the medication cart inspection.
Plan of correction
- Resident #4: PRN enema reordered 9/12/25 and is now present on the medication cart.
- Resident #5: PRN Glutose gel reordered 9/12/25; Glucagon emergency kit discontinued per provider order; expired PRN Oxycodone removed and disposed of per pharmacy protocol.
- Med Techs re-educated on verifying PRN medication presence and expiration during shift cart checks.
- RSD/designee will complete weekly cart audits x60 days.
- Pharmacy to review PRN stock quarterly with nursing leadership.
22VAC40-73-650-B
Based on observation and documentation, the facility did not ensure that each physician's order includes specific indications for administering each drug.
Evidence
- Resident #1 was administered PRN Systane eye drops during the inspection. Resident #1's record contained hospital documentation (dated 8/27/25) that states that the resident should begin using artificial tears 2-3 times per day, daily for the next two weeks (Systane, Refresh drops are recommended). Resident #1's MAR calls for the administration of one drop, 2-3 times every day as needed. No documentation was observed, during the inspection, that stated which eye (or both eyes) the Systane should be administered to.
Plan of correction
- Order suspended until clarification is received.
- PRN order remains active; staff instructed to administer only upon resident request.
- Nursing continues to contact physician for order clarification (calls documented).
- Policy updated to require escalation to ED after two unsuccessful attempts for clarification.
- All standing orders will be reviewed monthly for completeness and clarity.
22VAC40-73-640-A
Based on observation and interview, the facility did not implement a medication management plan to prevent the use of outdated medications and ensure that medications are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- Resident #2's August and September medication administration records (MARs) were reviewed during the inspection. Resident #2's MAR states that she was not administered her Amlodipine Besylate tablet on 8/16/25. The MAR states that the facility was waiting for the medication from the pharmacy/family. The morning medication administration for Resident #3 was observed during the inspection. Resident #3 was scheduled to receive Calcium Citrate during the morning medication pass, but the bottle of medication was observed to be expired. The expiration date on the bottle was listed as 09/23. Resident #3's MAR indicates that she was not administered Centrum Silver tablet on 9/1/25; her Lactase caplet on 8/13/25 (9 AM, noon and 5 PM administrations), 9/3/25 (5 PM administration), and on 9/4/25 (midnight administration). The MAR indicated that the medications had not been administered because the facility was waiting for the medications to arrive from the pharmacy/family. Resident #4's MAR indicates that she was not administered her Risaquad capsule on 9/1/25 (9 AM administration). The MAR states that the facility was awaiting the medication from the pharmacy/family. Resident #5's MAR indicates that he was not administered the following medications, as the medications were listed as awaiting the medication from the pharmacy/family: Gabapentin (8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/15/25) Wixela inhaler (8/9/25 - 8 PM administration, 8/10/25, 8/11/25, 8/13/25 - 8 AM administration), 8/14/25, 8/15/25, 8/16/25, 8/17/25, 8/18/25 - 8 AM administration) Duloxetine (8/7/25, 8/10/25, 8/12/25, 8/13/25, 8/14/25, 8/15/25, 8/17/25, 8/18/25, 8/19/25, 8/20/25, 8/21/25, 8/25/25) Mupirocin (8/14/25 - 9 PM administration, 8/18/25 - 9 PM administration) Diltiazem (8/15/25)
Plan of correction
- Resident #2: Missed medication received within the next cycle and administered.
- Resident #3: Calcium Citrate and Lactase discontinued per MD order; MAR updated.
- Resident #5: Gabapentin delay resolved when physician order was received; Wixela discontinued by provider order; Duloxetine filled once signed order set received; Mupirocin refusal documented correctly after refresher training.
- Pharmacy refresher class scheduled for all Med Techs.
- Quickmar refresher required for all new hires before first med pass.
- RSD to conduct daily MAR reviews for 14 days, then weekly for 60 days.
- Families no longer primary suppliers unless documented in care plan.