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: April 10, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 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:

Standard #:	22VAC40-73-350-B
Description:	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.
Standard #:	22VAC40-73-640-A
Description:	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.
Standard #:	22VAC40-73-680-D
Description:	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 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.