VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mulberry Creek Assisted Living
400 Blue Ridge Street
Martinsville, VA 24112

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Jan. 10, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 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:

Standard #:	22VAC40-73-40-B-8
Description:	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.
Standard #:	22VAC40-73-50-A
Description:	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.
Standard #:	22VAC40-73-120-A
Description:	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.
Standard #:	22VAC40-73-250-C
Description:	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.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and staff interview, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of a current screening form published by the Virginia Department of Health or a form consistent with it. 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.
Standard #:	22VAC40-73-390-A
Description:	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. 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.
Standard #:	22VAC40-73-410-A
Description:	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.
Standard #:	22VAC40-90-30-B
Description:	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.
Standard #:	22VAC40-90-40-B
Description:	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.