VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Reflections-A Senior Living Community
246 West Market Street
Leesburg, VA 20176
(703) 777-1971

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: April 30, 2021 and May 6, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 4/30/2021 and concluded on 5/6/2021. A self-reported incident was received by the department regarding allegations in the areas of resident safety. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. LI reviewed one resident record and interviewed the administrator. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. A violation not related to the self-report was found and cited. The exit interview was completed with the administrator via telephone on 5/6/2021. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based upon a review of resident records and interview with administration, the facility failed to ensure that the Medication Administration Record (MAR) shall include: diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: The April 2021 Medication Administration Record (MAR) for Resident #1 did not include the diagnosis, condition, or specific indications for administering the following medication: Quetiapine Fumarate.
Plan of Correction:	I. Corrective Action Diagnosis was added to the MAR (Medication Administration Record) for Resident #1. II. How to Identify other missing information on the MAR. Director of Resident Care (DRC) and/or designee will audit all current MARs to make sure all medications include diagnosis, condition or specific indications. III. Systemic Changes DRC and/or designee will review all new medications entered into Extended Care Professional (ECP) to ensure the medications include diagnosis, condition or specific indications. IV. Monitoring Process DRC and/or designee will review quarterly and on an as needed basis all MARs to ensure they include diagnosis, condition or specific indications.