Inspection Reports for
Reflections-A Senior Living Community
246 West Market Street, LEESBURG, VA, 20176
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
28 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the Fairfax Licensing Office on February 28, 2025, regarding Resident Care and Related Services and Resident Accommodations and Related Provisions.
Complaint Details
Complaint related inspection triggered by allegations in Resident Care and Related Services and Resident Accommodations and Related Provisions; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt of the inspection summary.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 28
Deficiencies: 4
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure preliminary plans of care were properly signed, improper medication storage in resident rooms, unavailability and improper storage of PRN medications, and unauthorized use of portable heating units.
Deficiencies (4)
Facility did not ensure that a preliminary plan of care is developed and signed by the licensee/administrator or designee, and by the resident or legal representative.
Facility did not ensure medication storage in resident rooms is limited to out-of-sight places for residents not capable of self-administering medication.
Facility did not ensure that PRN medication is available and properly stored; expired medications were found and PRNs were not available at time of inspection.
Facility did not ensure portable heating units are only used to provide or supplement heat in the event of a power failure or similar emergency.
Report Facts
Number of residents present: 28
Number of resident records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 2
Medication expiration dates: Nov 19, 2024
Medication expiration dates: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Dec 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 12/16/24 regarding allegations in multiple areas including Administration, Personnel, Staffing, Resident Care, Resident Accommodations, and Buildings and Grounds.
Complaint Details
Complaint related: Yes. The complaint involved allegations in Administration, Personnel, Staffing, Resident Care, Resident Accommodations, and Buildings and Grounds. The evidence supported some allegations related to Resident Care and Buildings and Grounds.
Findings
The investigation supported some, but not all, allegations. Non-compliance was found in Resident Care and Related Services and Buildings and Grounds. Specific violations included failure to ensure individualized service plan updates were signed and dated, and operable windows lacking effective screens.
Deficiencies (2)
Facility did not ensure that individualized service plan (ISP) updates are signed and dated by the licensee/administrator/designee, and by the resident/legal representative.
Facility did not ensure that each operable window is effectively screened.
Report Facts
Number of residents present: 28
Number of resident records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 22
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
The inspection was a monitoring inspection conducted on June 17, 2024, to review various areas including administration, personnel, resident care, building and grounds, and emergency preparedness.
Findings
The inspection found no violations of applicable standards or laws. Observations included residents participating in activities and proper medication administration. The inspection summary will be posted publicly within five business days.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 16
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Monitoring
Census: 20
Deficiencies: 0
Date: Jul 7, 2023
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of admission and discharge of residents and resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Report Facts
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
Inspection Report
Monitoring
Census: 22
Deficiencies: 1
Date: Apr 25, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance related to medication administration records, specifically missing initials of direct care staff and documentation of medication errors or omissions.
Deficiencies (1)
The facility failed to ensure that the Medication Administration Records (MARs) included initials of direct care staff administering medications and documentation of any medication errors or omissions.
Report Facts
Number of residents present: 22
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of resident interviews: 1
Number of staff interviews: 1
Inspection Report
Renewal
Census: 14
Deficiencies: 0
Date: Nov 8, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection included review of resident and staff records, activity calendar, menus, schedules, oversight reports, fire drills, and background checks. No violations were found and no deficiencies were issued.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of resident care. The investigation included telephone contact with the administrator and an on-site observation.
Complaint Details
A complaint was received regarding resident care. The investigation was conducted through documentation review, telephone contact with the administrator, and an on-site observation. The complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Inspection Report
Monitoring
Deficiencies: 1
Date: Apr 30, 2021
Visit Reason
A focused monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of resident safety. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation did not support the self-report of non-compliance; however, a violation unrelated to the self-report was found regarding incomplete information on the Medication Administration Record (MAR).
Deficiencies (1)
The facility failed to ensure that the Medication Administration Record (MAR) included diagnosis, condition, or specific indications for administering the drug or supplement for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Inspector | Named as the current inspector conducting the inspection. |
| Director of Resident Care | DRC | Responsible for auditing MARs and implementing corrective actions. |
Inspection Report
Renewal
Census: 14
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
A renewal inspection was initiated on December 7, 2020 and concluded on December 8, 2020 to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations with applicable standards or law. No deficiencies were issued during this renewal inspection.
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