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: Dec. 8, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 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:

Standard #:	22VAC40-73-670-2
Complaint related:	Yes
Description:	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 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: 1. 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. 2. 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. 3. 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.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	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. 4) Trends will be reviewed weekly by clinical staff to ensure compliance.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	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: 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.