Inspection Reports for
Sunshine Villa, A Merrill Gardens Community

The visit was complaint-related due to two elopements by residents R1 and R2. The complaint was substantiated with findings that the facility failed to provide adequate supervision and redirection to prevent elopements.

The investigation found that residents R1 and R2, both with neurocognitive disorders and wandering behaviors, left the facility unassisted and were returned by local law enforcement. The facility staff failed to redirect the residents and were unaware of one elopement, posing immediate health, safety, and personal rights risks. An immediate civil penalty of $500 was issued for absence of supervision.

The visit was triggered by a complaint/incident report regarding a medication error involving Resident R1. Staff S1 admitted to administering two doses of medication M1 without conducting the required medication checks. The complaint was substantiated by the investigation.

The investigation confirmed that Staff S1 administered two incorrect doses of medication M1 to Resident R1, resulting in a medication error. A deficiency was issued for failure to meet personnel requirements related to medication administration.

The complaint investigation was triggered by allegations received on 01/18/2022 regarding failure to follow COVID-19 protocols, untimely response to call buttons, untimely medication administration, and untimely showers. The COVID-19, call button, and medication allegations were found unsubstantiated. The shower allegation was substantiated based on review of shower logs and interviews.

The investigation found the allegations regarding COVID-19 protocols, call button response times, and medication administration to be unsubstantiated. However, the allegation that residents were not receiving showers timely was substantiated due to discrepancies in shower logs for one resident, indicating the facility was not meeting hygiene needs.

The complaint investigation was substantiated for allegations that staff did not ensure resident R1 was administered medications as prescribed, specifically delivering wrong insulin and delaying the correct insulin administration by over an hour on 2023-11-09. The complaint that staff did not respond timely to resident communication requests and did not ensure resident's representative participation in care decisions was unsubstantiated.

The investigation substantiated that staff delivered the wrong insulin to resident R1 on 2023-11-09 and delayed delivering the correct insulin for over an hour, failing to meet resident health needs. Additionally, staff were found insufficiently trained and not competent in medication administration. Another complaint regarding staff response to resident communication requests and participation of resident's representative in care decisions was unsubstantiated.

The inspection found deficiencies related to failure to submit an incident report for a resident fall and incomplete medication records lacking start dates in the centrally stored medication log. The facility was otherwise inspected for safety, food storage, and environmental conditions with no obstructions noted.

The visit was complaint-related due to a report that resident R1 left the facility without notice on 10/01/2023 and was returned by the spouse the same day. The complaint was investigated during the visit.

Deficiencies were noted related to personnel requirements, specifically that facility personnel were not sufficient in numbers and competent to meet resident needs, as evidenced by the incident involving resident R1 leaving without notice and returning after 6:00 PM the same day.

Case management was initiated due to an incident report of a resident elopement on 02/24/2023. The resident was not permitted to leave unattended and was found outside the community. The facility did not detect the elopement during peak hours despite staff monitoring exits.

The facility failed to ensure staff attempted to redirect the resident from leaving unassisted, posing an immediate health and safety risk. The resident was found outside the community by a pedestrian and returned by the responsible person. The facility is installing delayed egress devices to prevent future elopements.

The facility was generally clean, well maintained, and staff were observed wearing masks with most residents and staff vaccinated. However, water temperatures in resident bathrooms exceeded the maximum allowed temperature, posing a potential safety risk.

The complaint was substantiated based on interviews, observations, and record review. The investigation included multiple visits, interviews with residents and staff, and review of resident records. The facility was found to have inadequate staffing and failure to meet residents' care needs during the COVID-19 outbreak.

The investigation found substantiated deficiencies including insufficient staffing during a COVID-19 outbreak, resulting in residents not receiving timely personal care such as bathing and delayed responses to alarms, posing immediate risks to residents' personal rights.

The complaint investigation was substantiated regarding inadequate food service and barricading of residents' rooms. The allegation that the facility failed to meet residents' needs was unsubstantiated.

The investigation substantiated that meals provided did not meet the modified diets prescribed by physicians for certain residents, and that barricades were erected to block doors of dementia residents, posing immediate risks to personal rights. Another allegation that the facility failed to meet residents' needs was found unsubstantiated.