MUIRWOODS MEMORY CARE

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interviews and file review, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents in care.

Official plan of correction

Licensee/Administrator to submit in-service retraining to all staff on elopement protocols. Trainings & Documents to be submitted to LPA by POC due date 6/25/2026. Disciplinary action taken on 2 care givers -

Deadline recorded: Jun 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and MedTech record review, the licensee did not comply with the section cited above in that R7 has prescription for zinc oxide that was not listed on the Centrally Stored Medication Log, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2026 Plan of Correction Facility to conduct medication training. Training conducted to satisfy deficeincy of HSC1569.69 can count toward satisfying the training required to clear this deficiency. Facility to submit plan to CCL to conduct maintaining proper medication records training for all staff administering medication by plan of correction due date. Training to be completed no later than 5/21/26

Official classification

Type A

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in that S2 and S3 MedTechs did not have the required medication training completed on file, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2026 Plan of Correction Facility to conduct medication training. Facility to submit plan to CCL to required medication training for all staff administering medication by plan of correction due date. Training to be completed no later than 5/21/26.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and MedTech observation, the licensee did not comply with the section cited above in that Bubble pack for Escitalopram 20mg had a start date of 4/21/26 and a beginning quantity of 30, but only four (4) pills remain, so bubble pack is missing 2 tabs, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2026 Plan of Correction Facility to conduct medication training. Training conducted to satisfy deficeincy of HSC1569.69 can count toward satisfying the training required to clear this deficiency. Facility to submit plan to CCL to conduct proper medication handling training for all staff administering medication by plan of correction due date. Training to be completed no later than 5/21/26

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation the licensee did not comply with the section cited above in that LPA observed pre=poured medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2026 Plan of Correction Facility to self-certify they will cease pre-pouring medications on LIC9098 by plan of corrections due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S5 did not have the required number of hours completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/28/2026 Plan of Correction Facility to complete training for S1 and S5 in the duration and subject matters required per regulation HSC 1569.625(b)(2) by plan of correction due date.

Official classification

Type B

Official code

1569.69(g)

Regulation authority

HSC

What the official deficiency says

(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in that the last consulation was over 6 months ago, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction Facility to arrange for pharmacy consulation review of facility's medication managemnt program by plan of correction due date. Documentation of review to be submitted to CCL.

Official classification

Type B

Official code

87463(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in that Residents R1, R3, R4, and R5 all had physician reports that were not current, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction Facility to submit to CCL current physician reports for R1, R3, R4, and R5 by plan of correction due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that medication for R1 was administered approximately three (3) hours later than the prescribed time which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee or Administrator will submit proof of Medication Policy training for all of the facility's Medical Technicians to Community Care Licensing by POC due date of 3/11/2026.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(F)

Regulation authority

CCR

What the official deficiency says

87307(a)(3)(F) Personal Accommodations and Services: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement is not met as evidenced by : Based on interviews, observations, and records reviewed Licensee did not ensure resident laundry was completed, leaving laundry in other residents’ rooms, not finishing laundry in an appropriate time. This poses a potential Health and Safety risk to residents in care.

Official plan of correction

New Administrator has reinforced old laundry system with a main staff conducting 5 days a week with NOC shift completing remainder from the day that was not, by laundry staff. And another primary from housekeeping is doing other 2 days regularly. Reinstatement of old laundry system started 10/1/2025. POC cleared at visit.

Deadline recorded: Oct 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's & Administrator observation during facility tour, the licensee did not comply with the section cited above finding Janitorial Closet on Side 1 left adjar/open containing toxic cleaning chemicals & storage closet 1 unlocked containing electrical panel by rm 19, accessible to dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/21/2025 Plan of Correction Administration shall provide Acknolegement of regulation and training refresher objectives by 4/21/2025 & provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL by 4/25/2025 in order to clear the deficiency.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA & Administrator observation and interview with Regional Dir. of Health & Wellness , the licensee did not comply with the section cited above in finding 26 missing window screen between the inside & exterier of the facility which poses/posed a potential health, safety or personal rights risk to persons in care. Regional Dir infomred they have replaced 14 screens already.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction LIcensee to finish replacement of 26 window screens and fix additional damaged screens and submit receipt of repair/replacement to CCL for proof of correction due 5/2/2025 to clear POC.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Bases on pictures provided and staff interviews facility did not comply with above regulation regarding incontinence care needs being met and staff double briefing. This poses an immediate Health and Safety risk to clients in care.

Official plan of correction

Facility Administrator to submit a written response on how they handled the situation by 1/30/2025.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs... & brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidence by: Based on interviews and record review the licensee failed to seek medical attention after observing R1’s injury, which poses an immediate risk to the health and safety of the residents in care.

Official plan of correction

Administrator to submit a statement that they understand regulation 87466 and shall be in future compliance ensuring residents are regularly observed for changes as the Plan of Correction (POC) by due date to clear the citation.

Deadline recorded: Jan 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(2)Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidence by: Deficient Practice Statement Based on LPA & DHS's observation, the licensee did not comply with the section cited above in 7out of 9 bedrooms inspected contained different items: mouthwash with alcohol, nail polish, spray cans of air freshiner, sewing needle, creams, ointments, shampoo & conditioners in rooms that some are not locked and other residents could enter, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/15/2024 Plan of Correction 1)Facility to send in written plan they understand regulation and how it will be followed by (4/15/2024) 2)Facility will conduct and send proof of staff training of regulation with name of training, staff names, signatures & dates by POC due date of 4/19/2024. to clear citation.

Official classification

Type A

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement was not met based on record review, This is an immediate risk to health and safety.

Official plan of correction

Facility agrees to conduct an in-service with all staff regarding their Grooming Policy and provide proof of training to CCL no later than POC due date, 7/25/2023.

Deadline recorded: Jul 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. Requirement was not met as evidenced by: document review, R1 was not given medication as prescribed. This is an immediate health and safety risk to resident in care.

Official plan of correction

Administrator to submit log for in-service training regarding medication handling by POC due date, 10/1/2021.

Deadline recorded: Oct 1, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Sec. 87608. This requirement is not met as evidenced by: Based on interviews, obs & doc review, facilitydid not comply w/section above on 39out of39 needs of residents which poses an immediate risk for resident in care. Facility has 4 caregivers at AM & PM shift for 39 residents w/ 4 being 2 people assist, and 39 needing assistance w/ daily living.

Official plan of correction

Facility agrees to ensure that they will have enough staff at all times according with the number of residents and their needs. Facility to provided Department w/ plan for staffing immediately due to concerns of insufficient staffing and no later then POC due date of 9/1/21. Plan should stated how facility will acquire staff and staff schedule for facility w/ addition of staff needed.

Deadline recorded: Sep 1, 2021. A deadline is not proof that correction was completed.