Virginia DSS · Assisted Living Facility

Mulberry Creek Assisted Living

📍 400 Blue Ridge Street, Martinsville, VA, 24112

ID 50184One Year licenseClosed
11
Inspections
On record
5
With violations
Visits that cited something
6
Clean visits
Nothing cited
20
Violations cited
Individual findings
18
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Mulberry Creek Assisted Living was inspected 11 times between October 31, 2023 and October 9, 2025 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 20 violations under 18 distinct standards. 4 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 and no longer serves any of these on its site. All 11 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
05/30/2026
Administrator
Kailey Joyce
Licensing inspector
Holly Copeland
Inspector phone
(540) 309-5982
Approved for
Residential and Assisted Living Care · Non-Ambulatory

Inspection History

11

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

October 9, 2025Inspection1 violation
Inspection dates
Oct. 9, 2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
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: 10/09/2025 from 11:15 AM to 11:45 AM 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 07/25/2025 regarding allegations in the area(s) of: Administration and Administrative Services Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 18 Number of staff records reviewed: 1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 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 self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-80
Based on record review and staff interview, the facility failed to ensure that if the facility assists with the management of personal funds, no resident funds shall be used for purposes of personal interest by the facility staff.
Evidence
  1. On 07/25/2025, LI received a phone call from staff 1 reporting that an investigation of staff 2 was in progress for suspicion of misappropriation of resident funds. Staff 1 also indicated that local law enforcement was also working with the facility to determine the total dollar amount, and which residents were affected.
  2. On 08/21/2025, LI received a written update from staff 1 on the investigation which confirmed that staff 2 was no longer employed at the facility as of 07/25/2025, and staff 1 had indicated the name of the local law enforcement investigator who was assisting with the investigation at the facility.
  3. On 10/09/2025, LI performed an on-site follow-up to the self-report and reviewed and obtained documentation that was compiled by staff 1 regarding an approximate total of $2,582 that was misappropriated from 18 resident accounts since February 2025. Staff 1 revealed to LI that as a result of the facility’s investigation, the previous employee (staff 2) has been charged for embezzlement by local law enforcement; however, the facility has reimbursed all 18 affected residents.
Plan of correction
Not published by VDSS.
July 22, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 63149 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/22/2025 from 09:45 AM to 11:00 AM 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 07/18/2025 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 did not support the allegation(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 25, 2025Inspection4 violations
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 03/25/2025 from 08:45 AM to 03:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on record review and staff interview, the facility failed to ensure that the report of physical examination shall be completed for all fields.
Evidence
  1. On the date of inspection, on the REPORT OF PHYSICAL EXAMINATION for resident 1, the following fields were blank or incomplete: The person’s address and telephone number; Significant medical history; Description of the person’s reactions to allergies.
  2. An interview with staff 4 was unsuccessful at locating a REPORT OF PHYSICAL EXAMINATION for resident 1 where all fields were completed.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observation and staff interview, the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. During a physical plant walk-through of the facility on the date of inspection, at 09:50 AM and 02:40 PM, LI did not see any menu (day or weekly) for meals and snacks that was posted within the facility.
  2. A discussion with staff 4 was unable to identify any area(s) of the facility where the weekly menu was posted for residents.
Plan of correction
Not published by VDSS.
22VAC40-73-650-A
Based on record review, observation, and staff interview, the facility failed to ensure that no medication or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber ? medications include prescription, over-the-counter, and sample medications.
Evidence
  1. During the physical plant walk-through of the facility on the date of inspection, at 08:59 AM, LI observed a bottle of CVS Health Artificial Tears and a tube of CVS Health Ultra Strength Muscle Rub pain relieving cream on the nightstand next to resident 7’s bed.
  2. A review of resident 7’s record revealed that she does not have physician’s orders for the use of artificial tears nor the muscle rub.
  3. An interview with staff 4 on the date of inspection confirmed that there are no physician’s orders for the use of the artificial tears or the muscle rub that were in resident 7’s room.
  4. During the physical plant walk-through of the facility on the date of inspection, at 09:36 AM, LI observed a tub of ARCTIC ICE PAIN RELIEVING GEL on the nightstand next to resident 5’s bed.
  5. A review of resident 5’s record revealed that she does not have physician’s orders for the use of pain-relieving gel.
  6. An interview with staff 4 confirmed that there are no physician’s orders for the use of pain-relieving gel that was in resident 5’s room.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician’s or other prescriber’s instructions.
Evidence
  1. During the on-site inspection, the record for resident 3 contained a medication order summary, signed 03/20/2025, for CARVEDILOL ORAL TABLET 3.125 MG “ Give 1 tablet by mouth two times a day for Heart Health ” Hold if SBP < 100 or HR < 60.
  2. A review of the February 2025 medication administration record (MAR) for resident 3, regarding the CARVEDILOL ORAL TABLET 3.125 MG, indicated that staff 5 administered that medication on the following dates and times even though the pulse reading (HR) was below 60: 02/09/2025 at 2000, resident 3’s pulse reading was 59; 02/12 at 2000, resident 3’s pulse reading was 58; 02/13 at 2000, resident 3’s pulse reading was 57; 02/23 at 2000, resident 3’s pulse reading was 57; 02/26 at 2000, resident 3’s pulse reading was 57; 02/27 at 2000, resident 3’s pulse reading was 56.
  3. A review of the March 2025 MAR for resident 3 regarding the CARVEDILOL ORAL TABLET 3.125 MG, indicated that staff 5 administered that medication on the following dates and times even though the pulse reading (HR) was below 60: 03/04/2025 at 2000, resident 3’s pulse reading was 57; 03/07 at 2000, resident 3’s pulse reading was 57.
  4. An interview with staff 4 on the date of inspection confirmed that staff 5 had administered the medication on dates and times when the pulse reading (HR) was outside of the ordered parameter.
Plan of correction
Not published by VDSS.
March 25, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 61655 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/25/2025 from 08:45 AM to 03:45 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 02/16/2025 regarding allegations in the area(s) of: Personnel; Resident care and related services Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: Staff schedule also reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 10, 2024Complaint survey0 violations
Inspection dates
Dec. 10, 2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 60894 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/10/2024 from 12:15 PM to 12:45 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 11/19/2024 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: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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 did not support the allegation(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2024Inspection0 violations
Inspection dates
Sept. 24, 2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 09/24/2024 from 11:00 AM until 12:00 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 VDSS Division of Licensing on 09/05/2024 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 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 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 13, 2024Inspection0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 06/13/2024 from 11:30 AM until 01:00 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 VDSS Division of Licensing on 06/06/2024 regarding allegations in the area(s) of: Resident care and related services and mixed population. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 10, 2024Inspection3 violations
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 04/10/2024 from 08:45 AM until 02:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender and shall document in the resident’s record that this was ascertained and the date the information was obtained.
Evidence
  1. The record for resident 3, date of admission 11/10/2023, contained documentation that a sex offender search had occurred on 04/09/2024.
  2. Interview with staff 4 revealed that there were no sex offender checks for resident 3 prior to admission.
Plan of correction
1) A 100% audit of all current residents was completed to ensure sex offender checks were completed and placed/uploaded to resident charts. 2) Education was provided to the administrator and the admissions coordinator on the requirements for completing sex offender checks for all admission prior to admission to the facility. The checks will be completed and placed/uploaded to all resident charts. 3) All admissions will be checked by the administrator for sex offender checks prior to admissions. 4) Trends will be reviewed to ensure compliance.
22VAC40-73-640-A
Based on observation, staff interview, and document review, the facility failed to implement a portion of its medication management plan, specifically regarding methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. The medication management plan for the facility, last revised on 07/17/2023, states that medications in storage or refrigeration are checked daily for expiration dates.
  2. The unit 2 medication cart contained a BASAGLAR KWIKPEN 100UNIT/1ML insulin pen for resident 5, with a filled date of 03/21/2024, with instructions to INJECT 10 UNITS SUBCUTANEOUSLY AT BEDTIME FOR DIABETES MELLITUS. The bag that contained the insulin pen contained a label which stated "STORE IN REFRIGERATOR UNTIL OPEN. ONCE OPEN MAY STORE AT ROOM TEMPERATURE FOR ____ DAYS". The bag also contained a blank label with fields for DATE OPENED, EXP. DATE, and INITIAL.
  3. The insulin pen itself was not labeled with an open date or expiration date, and it was reading as being about halfway full of insulin based on the plunger location in the tube.
  4. Staff 1 confirmed to LI that this insulin pen appeared to have been used but there was no open date or expiration date indicated.
Plan of correction
1) A 100% cart audit was complete of all medication carts to ensure all multiuse medications were labeled with the date in which the medication was opened. 2) Education was completed with all current RMA’s regarding the policy on medication storage and labeling. 3) The administrator/designee will complete medication cart audits 3 times weekly to ensure compliance with medication storage and labeling. 4) Trends will be reviewed to ensure compliance.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered in accordance with physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 2 contained physician’s orders, signed 03/21/2024, for the following heart medication with parameters: CARVEDILOL ORAL TABLET 3.125 MG “Give 1 tablet by mouth two times a day for Heart Health ” Hold if SBP < 100 or HR < 60?. On the March 2024 medication administration record (MAR) for resident 2, on 03/12/2024 at 20:00, the blood pressure reading was noted as 99/48 and the pulse (heart rate) reading was 58; however, the MAR also indicated that the CARVEDILOL medication was checked as given on that date and time. On the April 2024 MAR for resident 2, on 04/06/2024 at 08:00, the blood pressure reading was 115/89 and pulse (heart rate) was 61; however, the exception note on that date and time indicates that the CARVEDILOL was held ?Pulse below 60/min?. On 04/07/2024 at 08:00, the pulse (heart rate) reading was 56; however, the MAR also indicated that the CARVEDILOL medication was checked as given on that date and time. On 04/08/2024 at 08:00, the pulse (heart rate) reading was 60; however, the exception note on that date and time indicates that the CARVEDILOL was held “Pulse below 60/min”.
  2. The record for resident 2 contained physician’s orders, signed 03/21/2024, for the following heart medication with parameters: FUROSEMIDE ORAL TABLET 40 MG “Give 2 tablet by mouth one time a day for CHF ” Hold if SBP < 100?. On the March 2024 medication administration record (MAR) for resident 2, on 03/06/2024 at 08:00, the blood pressure reading was 115/47; however, the exception note on that date and time indicates that the FUROSEMIDE was held ?Pulse below 60/min?. The orders for FUROSEMIDE do not indicate to hold based on the pulse reading. On 03/07/2024 at 08:00, the blood pressure reading was 123/53; however, the exception note on that date and time indicates that the FUROSEMIDE was held “Pulse below 60/min” The orders for FUROSEMIDE do not indicate to hold indicates that the FUROSEMIDE was held “Pulse below 60/min”. The orders for FUROSEMIDE do not indicate to hold based on the pulse reading. On the April 2024 MAR for resident 2, on 04/04/2024 at 08:00, the blood pressure reading was 136/56; however, the exception note on that date and time indicates that the FUROSEMIDE was held “Pulse below 60/min”. The orders for FUROSEMIDE do not indicate to hold based on the pulse reading. On 04/08/2024 at 08:00, the blood pressure reading was 134/66; however, the exception note on that date and time indicates that the FUROSEMIDE was held “Pulse below 60/min”. The orders for FUROSEMIDE do not indicate to hold based on the pulse reading.
  3. Staff 4 acknowledged to LI that there were some errors on March and April MARs for resident 2 regarding administration of CARVEDILOL and FUROSEMIDE.
Plan of correction
1) Education was provided to all current medication aides as to the proper procedure for administering medication with parameters. 2) A 100% MAR audit was completed to identify any irregularities in administration of medications with hold parameters. 3) Administrator/Designee will audit MARS 5 times weekly for a period of 3 months to ensure compliance 4) Trends will be reviewed weekly by clinical staff to ensure compliance.
January 10, 2024Inspection9 violations
Inspection dates
Jan. 10, 2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 01/10/2024 from 12:15 PM until 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-40-B-8
Based on observation and staff interview, the facility failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon entering the facility on 01/10/2024, LI observed that the facility’s previous license, under the previous licensee, was posted and that the new licensee’s conditional license was not posted. An email had been sent to the new licensee on 12/01/2023 at 04:06 PM which contained the conditional license and cover letter that indicates that it is necessary that the conditional license be prominently posted in the facility at all times.
Plan of correction
All requirements have been completed under new license.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to ensure that a statement was prepared for the resident and his legal representative, if any, that discloses the required information about the facility.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for staff 2 and staff 3, staff 1 revealed to LI that none of the resident records have been updated with a disclosure statement under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-73-120-A
Based on record review and staff interview, the facility failed to ensure that staff orientation shall occur within the first seven working days of employment.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for staff 2 and staff 3, staff 1 revealed to LI that none of the staff records have been updated with a staff orientation and initial training under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-73-250-C
Based on record review and staff interview, the facility failed to ensure that personal social data shall be maintained on staff and included in the staff record, to include date of hire and verification that the staff person received a copy of his or her current job description.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for staff 2 and staff 3, staff 1 revealed to LI that none of the staff records have been updated to reflect the date of hire and verification that the staff person received a copy of his or her current job description under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-73-250-D
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for staff 2 and staff 3, staff 1 revealed to LI that none of the staff records have been updated with an initial (7-day) tuberculosis assessment under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-73-390-A
Based on record review and staff interview, at or prior to the time of admission, there shall be a written agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator appropriate legal representative, and by the licensee or administrator.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for resident 1 and resident 2, staff 1 revealed to LI that none of the resident records have been updated to reflect resident agreement documentation under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-73-410-A
Based on record review and staff interview, the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call bell system, and a signed acknowledgment of having received the orientation by the resident, or legal representative shall be kept in the resident’s record.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for resident 1 and resident 2, staff 1 revealed to LI that none of the resident records have been updated to reflect this orientation under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-90-30-B
Based on record review and staff interview, the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for staff 2 and staff 3, staff 1 revealed to LI that none of the staff records have been updated with sworn disclosure documentation under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
22VAC40-90-40-B
Based on record review and staff interview, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. During the mid-way monitoring inspection for the conditional license on 01/10/2024, LI attempted to perform a 60-day follow up with facility staff under the new licensee to ensure compliance with regulations for licensed assisted living facilities and terms of the license issued by the department.
  2. Upon a review of records for staff 2 and staff 3, staff 1 revealed to LI that none of the staff records have been updated with a criminal history record report under the new licensee, which became effective 11/30/2023.
Plan of correction
All requirements have been completed under new license.
December 8, 2023Complaint survey3 violations
Inspection dates
Dec. 8, 2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 58538 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/08/2023 from 10:30 AM until 12:00 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 12/07/2023 regarding allegations in the area(s) of: Personnel and Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 4 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 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 some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident care and related services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-670-2
Based on observation, staff record review, and staff interview, the facility failed to ensure that an applicant for registration as a medication aide provided to the Virginia Board of Nursing
Evidence
  1. of successful completion of the education or training course required to act as a medication aide on a provisional basis for no more than 120 days before successfully completing any required competency evaluation. EVIDENCE:
  2. During the on-site complaint investigation on 12/08/2023, staff 2 indicated to LI that staff 1 was the RMA on duty that day in unit 2. During the inspection, LI observed staff 1 looking through the unit 2 medication cart and reviewing the e- MAR system at 10:35 AM. During this encounter, staff 1 revealed to LI that she has been working as a registered medication aide (RMA) since around February or March 2023, under the facility’s previous licensee. Staff 1 stated that she had taken the RMA curriculum training class in February 2023, had taken the exam, and was currently licensed as an RMA. Staff 1 revealed to LI that she did not have verification of her RMA licensure with her, but her current staff record, or Human Resources (HR) should have a copy.
  3. While performing the on-site complaint investigation on 12/08/2023, the record for staff 1 contained a signed job description, dated 02/07/2023, that staff 1 is a “Certified Medicine Aide” and ?is responsible for administering medications to residents as ordered by the attending physician and under the direction of the attending physician, charge nurse, and the Director of Nursing?. The record also contained a training certificate for staff 1 having completed the 68- hour Medication Aide Curriculum program, dated 02/01/2023. Alternately, the record for staff 1 did not contain evidence of RMA licensure nor did it contain a provisional RMA practice letter. Staff 2 indicated that she would have to locate and send verification that staff 1 is authorized to administer medications as an RMA.
  4. On 01/16/2024, staff 2 provided LI a training certificate for staff 1 having also completed the 68-hour Medication Aide Curriculum program on 07/29/2023. On 01/22/2024, staff 2 provided LI a copy of a letter, dated 12/26/2023, which indicated that staff 1 was authorized at that point to practice as a provisional medication aide and is eligible to take the RMA examination for licensure.
Plan of correction
1)The employee in question was immediately removed from the medication cart at the time the violation was identified. 2)An employee audit of all Registered Medication Aides employed with the facility was conducted to ensure proper documentation was on record for each employee. 3) Education was completed with Administration and Human Resources regarding the Virginia Board of Nursing requirements for working as a Registered Medication Aide. 4) The Administrator and Human Resources will ensure that all new hire Registered Medication Aides will evidence of certification prior to employment. All new medication aides who have not yet taken their state test will provide a provisional practice letter from the Virginia State Board of Nursing authorizing them to work for 120 days as a medication aide. 5) The facility will keep a record of all medication aides who plan to test. Upon successful completion of the state test, the certificate of completion will be kept in the employee file. If the employee does not successfully complete the state test, upon notification the employee will be removed from the position of medication aide until successful completion is met.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The December 2023 MAR for resident 1 contained orders for CARVEDILOL TAB 3.125 MG ? Take 1 tablet by mouth one time a day for hypertension. The orders also indicated to check BP and heart rate daily and to hold CARVEDILOL TAB 3.125 MG if systolic BP is less than 100 or heart rate less than 55.
  2. On the December 2023 medication administration record (MAR) for resident 1 on 12/05/2023, the heart rate (pulse) for resident 1 was recorded as 54; however, the MAR was signed by staff 1 as having given the CARVEDILOL medication.
  3. On 12/09/2023, the heart rate (pulse) for resident 1 was recorded as 44; however, the MAR was signed under staff 1 as having given the CARVEDILOL medication. On 12/10/2023, the systolic blood pressure reading was 90; however, the MAR was signed under staff 1 as having given the CARVEDILOL medication.
  4. Interview with staff 2 and signed statements by staff 1 and staff 6 revealed that staff 6 was the RMA who administered the CARVEDILOL medication on 12/09 and 12/10/2023 while logged in under staff 1 in the e-MAR system.
Plan of correction
1)Education was provided to all current medication aides as to the proper procedure for administering medication with parameters. 2) A 100% MAR audit was completed to identify any irregularities in administration of medications with hold parameters. 3)Administrator/Designee will audit MARS 3 times weekly for a period of 3 months to ensure compliance. ill b 4) Trends will be reviewed weekly by clinical staff to ensure compliance.
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the MAR shall include the initials of direct care staff administering the medication.
Evidence
  1. The December 2023 MAR for resident 1 indicated that staff 1 administered the 08:00 AM medications on 12/09 and 12/10; however, an interview with staff 2 and signed statements by staff 1 and staff 6 revealed that staff 6 was the RMA who administered the 08:00 AM medications on 12/09 and 12/10 while logged in under staff 1 in the e-MAR system.
Plan of correction
1) Education was provided to all direct care staff on the policy for documentation. All staff shall only document the care that they provided in PCC under their own credentials. Any employee found to be documenting under another employees? credentials shall be subject to disciplinary actions. 2) A 100% MAR audit was conducted to identify any irregularities in documentation of medication. 3) Administrator/designee will audit MARS three times weekly for 3 months to ensure compliance. 4) Trends will be reviewed with clinical staff weekly to ensure compliance.
October 31, 2023Inspection0 violations
Inspection dates
Oct. 31, 2023
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 30 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.