Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MULBERRY CREEK NURSING & REHAB CENTER
MARTINSVILLE, VA · 300 certified beds · Last Life Safety survey May 9, 2024
CMS Certification Number 495426 · first certified January 2020
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within VA
13 citations — more than 59% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 2 months from now. This facility’s last Life Safety survey was May 2024. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 30, 2020 | 0 |
| December 5, 2022 | 11 |
| May 9, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-05-09 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-12-05 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2022-12-05 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2022-12-05 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 1 | 2022-12-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-12-05 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2022-12-05 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-05-09 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 3
- Smoke Deficiencies 3
- Egress Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Smoke Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 9, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 24, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 24, 2024) |
December 5, 2022 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (January 27, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (January 27, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.