Inspection Reports for Mulberry Creek Assisted Living
400 Blue Ridge Street, VA, 24112
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
26% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
34 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 34
Deficiencies: 1
Oct 9, 2025
Visit Reason
The inspection was a monitoring visit conducted on October 9, 2025, following a self-reported incident received on July 25, 2025, regarding allegations in the area of Administration and Administrative Services.
Findings
The investigation supported the self-report of non-compliance related to misappropriation of resident funds by a former staff member. The facility reimbursed all affected residents, and local law enforcement charged the former employee with embezzlement.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that if it assists with the management of personal funds, no resident funds shall be used for purposes of personal interest by the facility staff. |
Report Facts
Residents present: 34
Resident records reviewed: 18
Staff records reviewed: 1
Interviews conducted with staff: 1
Amount misappropriated: 2582
Residents affected: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Jul 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-18 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related inspection triggered by allegations in Resident Care and Related Services and Buildings and Grounds. The complaint was not substantiated.
Report Facts
Number of residents present: 33
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
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-16 regarding allegations in the areas of Personnel and Resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint 61655 was investigated with no substantiation of the allegations.
Report Facts
Number of residents present: 34
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Deficiencies: 4
Mar 25, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for Mulberry Creek Assisted Living.
Findings
The inspection found multiple violations including incomplete physical examination reports, failure to post dated menus for meals and snacks, medication administration without valid physician orders, and medication administration not following prescribed instructions.
Deficiencies (4)
| Description |
|---|
| The facility failed to ensure that the report of physical examination was completed for all fields. |
| The facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents. |
| The facility failed to ensure that no medication or treatment was started, changed, or discontinued without a valid order from a physician or other prescriber. |
| The facility failed to ensure that medications were administered according to physician's or other prescriber's instructions. |
Report Facts
Medication administration dates with pulse below ordered parameter: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the renewal inspection. |
| Staff 4 | Interviewed staff member related to multiple deficiencies including physical exam reports, menu posting, and medication orders. | |
| Staff 5 | Staff member who administered medication outside of ordered parameters. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Dec 10, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-19 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint #60894 regarding resident care and related services was investigated and found unsubstantiated.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 30
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of 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. No deficiencies were noted in the report.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 32
Deficiencies: 0
Jun 13, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 13, 2024, following a self-reported incident received on June 6, 2024, regarding allegations in resident care and mixed population.
Findings
The investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Renewal
Deficiencies: 3
Apr 10, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection identified multiple violations including failure to ascertain and document sex offender status prior to admission, failure to implement medication management plan regarding labeling of multiuse medications, and failure to administer medications according to physician orders.
Deficiencies (3)
| Description |
|---|
| Facility failed to ascertain and document whether a potential resident is a registered sex offender prior to admission. |
| Facility failed to implement medication management plan to prevent use of outdated, damaged, or contaminated medications, specifically missing labeling on an insulin pen. |
| Facility failed to ensure medications were administered according to physician's instructions, with errors noted in administration of CARVEDILOL and FUROSEMIDE. |
Report Facts
Date of admission: Nov 10, 2023
Inspection duration hours: 5.75
Medication cart audit frequency: 3
MAR audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Current inspector conducting the renewal inspection |
| Staff 1 | Confirmed insulin pen was used without labeling | |
| Staff 4 | Interviewed regarding sex offender checks and medication administration errors |
Inspection Report
Monitoring
Deficiencies: 9
Jan 10, 2024
Visit Reason
The inspection was a mid-way monitoring visit conducted to ensure compliance with regulations for licensed assisted living facilities and terms of the conditional license issued by the department.
Findings
The inspection found multiple areas of non-compliance including failure to post the current license conspicuously, lack of required resident disclosure statements, incomplete staff orientation and training records, missing personal social data in staff records, absence of tuberculosis risk assessments, missing resident agreements, incomplete resident orientation documentation, and failure to complete sworn statements and criminal history reports for staff. All cited violations were noted with plans of correction completed under the new license.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure that the current license is posted in a place conspicuous to residents and the public. |
| Facility failed to ensure that a statement disclosing required information about the facility was prepared for residents and legal representatives. |
| Facility failed to ensure staff orientation occurred within the first seven working days of employment. |
| Facility failed to maintain personal social data on staff including date of hire and verification of receipt of current job description. |
| Facility failed to ensure each staff submitted tuberculosis risk assessment results prior to or within seven days of first work day. |
| Facility failed to ensure a written agreement/acknowledgement of notification was signed by resident/applicant and licensee at or prior to admission. |
| Facility failed to provide orientation for new residents and legal representatives including emergency procedures, mealtimes, and call bell system with signed acknowledgment. |
| Facility failed to ensure sworn statement or affirmation was completed for all employment applicants. |
| Facility failed to ensure criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Inspection duration: 0.75
License effective date: Nov 30, 2023
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Dec 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-12-07 regarding allegations related to personnel and resident care and related services at Mulberry Creek Assisted Living.
Findings
The investigation supported some of the allegations, identifying non-compliance in resident care and related services. Violations were found related to medication aide registration, medication administration not following physician instructions, and improper documentation of medication administration.
Complaint Details
The complaint was substantiated in part, specifically regarding resident care and related services. The complaint involved personnel and resident care issues, including medication aide registration and medication administration practices.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that an applicant for registration as a medication aide provided evidence of successful completion of required education or training before acting as a medication aide on a provisional basis. |
| Facility failed to ensure medications were administered in accordance with physician's instructions, including administering medication despite parameters to hold based on blood pressure and heart rate. |
| Facility failed to ensure that the medication administration record (MAR) included the initials of the direct care staff who actually administered the medication. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 2
Number of staff records reviewed: 4
Number of staff interviews conducted: 2
Medication Aide Curriculum hours: 68
Medication administration audit frequency: 3
Medication administration audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Copeland | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff 1 | Registered Medication Aide (RMA) | Named in findings related to medication aide registration and medication administration violations |
| Staff 2 | Staff interviewed and provided documentation and statements related to medication aide registration and medication administration | |
| Staff 6 | Registered Medication Aide (RMA) | Named in findings related to medication administration under another staff's login |
Inspection Report
Original Licensing
Deficiencies: 0
Oct 31, 2023
Visit Reason
Initial licensing inspection of Mulberry Creek Assisted Living facility to determine compliance with applicable standards and laws.
Findings
The inspection found no violations with applicable standards or laws. The inspection summary will be posted publicly within five business days.
Report Facts
Inspection duration (days): 30
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