Merrill Gardens at Willow Glen

87411 Personnel Requirements General -Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidence by: Based upon review of staff emergency call button system it was found that month of July 2025, the average wait time was within 20 minutes, from when the call button/pendant was pressed to when the call button/pendant was cleared which poses/posed a potential health, safety or personal rights risk to

Notification to department after hospice care starts

87632 Hospice Care Waiver (d)(2) The licensee shall notify the Department... initiation of hospice care services... five working days of admitting a resident already receiving hospice care services...This requirement was not met as evidenced by; Based on record review and interview, facility ADM stated she did not notifiy the deparment of the initiation of hospice care services for R1. This poses/posed a potential health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This was not met as evidenced by:Based on interviews, S2 mentioned an insulin pen, medication for R1 was found in R2s room, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by; Based on record review and interview the licensee did not ensure the facility was free of cockroaches. This poses an immediate health, safety and personal rights risk to residents in care.

1569.655 Increase in fee rates for elderly residents (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice...**This was not met as evidence by**

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self administered medications as needed.This requirement was not met as evidence by:

87465(h)(6)(E) 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: (E) The prescription number and the name of the issuing pharmacy. This requirement was not met as evidenced by: Licensee did not ensure that 5 out of 8 reviewed Centrally Stored Medication Logs had correct presciption numbers, which poses a potential health risk for residents in care.

Report specified resident events within seven days

87211 Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below...This requirement is not met as evidenced by: Based on interview conducted with the General Manager at the time, there was an incident that occurred on 4/6/22 where R2 complained of a facility caregiver being abusive. The General Manager at the time admitted to not filing an incident report to CCLD for unknown reasons which poses a potential health and safety risk for residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by: Based on observations LPA observed the top door hinge to be loose, a sign on the door stating disrepair and a nail in a ziplock bag from the missing nail on the door hinge. In addition, based on interviews conducted, it was indicatd that the door has been in disrepair for more than 2 months.

Keep prescriptions in original containers

87465 Incidental Medical and Dental Care:(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 has not been met as evidenced by: Based on observations made during the visit conducted on 4/20/2022, LPA observed facility to be pre-pouring medication in plastic organizers or small cups labeled for morning and with bedroom numbers. The medication observed were being dispensed in small cups for 24 to 48 hours in advance. Nevertheless, the facility is transferring residents' medications from the originally received container to small cups.

Record centrally stored prescriptions and refill data

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: Based on observations and record review, LPA and Med-tech observed 8 packs of Acetaminophen in the overstock cabinet to not be logged on the Centrally Stored Medication Record (CSMR). In addtion, LPA observed R1's eye drop not logged on the CSMR.

Dispose of unused medications with required witness

87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident... Based on observations, on 4/20/22, LPA observed a bin full of medication that needed to be destructed. In addition, on 11/7/24, LPA observed a full box of medications that needed to be destructed.

Facility personnel sufficiency and competence

87411 - Personnel Requirements - (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 records review and interviews, facility staffing levels were not high enough to meet the needs of residents between 05/22 and 06/02. This presented a potential risk to the health and safety of residents in care.