Inspection Reports for
Merrill Gardens at Brentwood

The Licensing Program Analyst toured the facility and observed that all areas were maintained safely and adequately. No deficiencies were found during the visit, and staff and resident records were current and complete.

The complaint investigation 15-AS-20241210103140 initially substantiated the allegation that the facility was short staffed; however, all allegations were later amended to be unsubstantiated.

The Licensing Program Analyst amended the complaint to show all allegations as unsubstantiated, including the initial substantiated allegation of short staffing, which was changed to unsubstantiated.

The complaint involved multiple allegations including facility being short staffed, staff not treating residents with dignity and respect, and the facility being unsecured. After interviews with staff and residents and review of records, all allegations were found unsubstantiated due to lack of preponderance of evidence.

The investigation found that although some allegations such as staff shortages and facility security issues may have occurred or be valid, there was insufficient evidence to substantiate any violations. All allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included failure to follow infection control guidelines, reporting requirements, facility disrepair, temperature maintenance, and ensuring staff health. Evidence showed compliance with infection control, timely reporting, and appropriate staff health measures.

The investigation found all allegations to be unsubstantiated. The facility followed infection control guidelines, submitted required reports timely, residents were not affected by HVAC issues despite kitchen disrepair, and staff health protocols were followed with COVID-19 positive staff isolating appropriately.

The Licensing Program Analysts toured the facility and reviewed staff and resident records, vehicle maintenance logs, and safety equipment. No deficiencies were observed during the visit, though several documents were requested to be submitted by 05/16/2024.

The inspection found that the facility staff requested updated physician documentation and held a conference call with the resident's family regarding continuing care. No deficiencies were cited during this visit.

The complaint investigation was unsubstantiated, meaning that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove that the alleged violations occurred.

The investigation found that the facility does not have a backup generator but uses an inverter with battery packs providing electricity for 90 minutes, and staff are trained on safety procedures. Regarding falls in the shower, residents expressed concerns about falling and the need for additional grab bars, but installation requires written approval and residents are responsible for costs. Both allegations were determined to be unsubstantiated.

The complaint involved allegations that staff sexually harassed a resident and did not safeguard the resident's personal belongings. Interviews revealed conflicting accounts and insufficient evidence to substantiate the claims, resulting in an unsubstantiated determination.

The investigation included interviews with staff and residents and review of documents. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations occurred.

The allegation was that a resident had a seizure due to incorrect dosage of medication. The complaint was found to be unsubstantiated as there was no preponderance of evidence to prove the allegation.

The investigation found no proof that the seizure incident was caused by incorrect medication dosage by staff. Based on records and interviews, the resident had a history of seizures, and the allegation was unsubstantiated.

The complaint investigation was unannounced and conducted on 04/04/2023. The allegations were found to be unsubstantiated, meaning there was insufficient evidence to prove the allegations occurred.

The investigation found all allegations to be unsubstantiated based on interviews and records review. The resident was not forced to shower, the change in care level was discussed with the resident's representative but not implemented due to the resident moving out, and no overcharging occurred as charges were consistent and a prorated refund was issued.

The complaint alleged that an authorized representative was being charged extra fees. The allegation was found to be unsubstantiated based on records review and interviews, with no preponderance of evidence to prove the allegation.

The investigation found no evidence of extra charges being added to the invoices. Interviews and records review showed that although extra fees were discussed, no charges were applied since the authorized representative did not agree to them. The allegation was determined to be unsubstantiated.

The complaint alleged insufficient staff to meet the needs of the residents. The allegation was investigated and found to be unsubstantiated based on staff schedules, observations, and interviews.

The investigation found that the facility had sufficient staffing for all three shifts, with Med Tech, support staff, and agency staffing available. Residents were observed to be calm and comfortable, and staff interviews confirmed adequate staffing on the day in question. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The Licensing Program Analyst discussed infection control topics with the Administrator, who stated she will complete all recommendations. No deficiencies were cited.

The Licensing Program Analyst reviewed multiple operational areas and found the facility ready to be licensed with no deficiencies cited or observed during the presentation.

The facility was found to be clean, in good repair, and compliant with all observed requirements. No deficiencies were cited or observed during the inspection.

The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, training, grievances, complaints, medication management, and application document requirements.