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 25, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: LI entered the facility at 8:45 am on 4/25/2023 and exited at 3:15 pm on 4/25/2023 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: 22 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed residents eating breakfast and engaging in activities. LI inspected the medication carts. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based upon a review of records the facility failed to ensure that the Medication Administration Records (MARS) included the following: initials of direct care staff administering the medications, and any medication errors or omissions. Evidence: 1. On 4/25/2023, LI found the following information documents in sampled resident records: a. The April 2023 MAR for Resident #2 evidenced there were no initials or reason for omission for the medication of Levothyroxine on 4/14/2023 at approximately 6 am. b. The April 2023 MAR for Resident #4 evidenced there were no initials of reason for omission for medications Acetaminophen on 4/14/2023 and 4/24/2023 at approximately 6 am: Acetaminophen on 4/12/2023 and 4/24/2023 at approximately 6 pm. c. The April 2023 MAR for Resident #6 Evidenced there were no initials or reason for omission for medications Acetaminophen on 4/22/2023 and 4/23/2023 at approximately 3 pm; Menthol-Zinc Oxide on 4/22/2023 and 4/23/2023 at approximately 2 pm; Warfarin on 4/3/2023, 4/12/2023, and 4/19/2023 at approximately 6pm; Levothyroxine, Famotidine, Lidocaine Patch at approximately 6 am; Gabapentin on 4/22/2023 and 4/23/2023 at approximately 2 pm.
Plan of Correction:	1. All residents MARS were reviewed and checked for accuracy as well as documentation of staff initials. Staff that were on shift where the medication errors were found were re-educated on the importance of making sure all medications are documented and initialed in the MAR. 2. Director of Resident Care (DRC) and/or designee will audit all current MARS to make sure all staff are documenting on whether medication was given or omitted. 3. DRS and/or designee will review all MARS on a weekly basis to ensure all staff are documenting and signing off on medications given or omitted. 4. DRS and/or designee will review on a regular basis and as needed to ensure all medications have initials and documentation with specific indications if any medications are omitted or residents have refused.