Reflections - A Senior Living Community

Documentation was discussed with the provider.

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: 2/26/26 (9:45 AM - 6:30 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: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Four Number of staff records reviewed: Three Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, Medication Administration, Activities Additional Comments/Discussion: N/A 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. 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.

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: 4/3/25 (1:50 PM - 3:30 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 2/28/25 in the area(s) of: Resident Care and Related Services; Resident Accommodations and Related Provisions. Number of resident records reviewed: One Number of interviews conducted with staff: Two Observations by licensing inspector: Facility documentation 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.

Buildings and grounds were discussed with the provider.

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: 12/19/24 (8:30 AM - 4:45 PM), 12/30/24 (4:15 PM - 5:10 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 12/16/24 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, Staffing and Supervision, Admission, Retention and Discharge of Residents, Resident Care and Related Services, Resident Accommodations and Related Provisions, Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Four Number of interviews conducted with residents: Two Number of interviews conducted with staff: Two Observations by licensing inspector: Building and Grounds, resident records, staff records Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services, Buildings and Grounds. 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.

Documentation was discussed with the provider.

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: 12/19/24 (8:30 AM - 4:45 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: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Four Number of interviews conducted with residents: Two Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, Medication Administration, Activity 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.

Type of inspection: Monitoring Inspection Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/17/2024 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: 4 Number of staff records reviewed: 16 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents participating in activity programs. This LI also observed medications being administered to residents and audit the med cart. Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

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 10:45 am on 7/7/2023 and exited at 1:50 pm on 7/7/2023. 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 VDSS Division of Licensing on 6/28/2023 regarding allegations in the area(s) of admission and discharge of residents and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 20 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

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

A renewal inspection was initiated on 11/8/2021 and concluded on 11/17/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 14. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, the activity calendar, monthly menu, staff work schedule, healthcare and dietary oversight reports, fire drill reports, annual health and fire inspection reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 12/14/2020 were reviewed. The inspector conducted the on-site portion of the inspection on 11/16/2021. An exit interview was conducted with the administrator on 11/17/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

A non-mandated complaint inspection was initiated on 6/28/2021 and concluded on 7/27/2021. A complaint was received by the department regarding allegations in the areas resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 7/27/2021. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

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.