Inspection Reports for Sunshine Villa, A Merrill Gardens Community

The inspection visit was an unannounced Case Management Incident visit triggered by a reported medication error discovered on 2025-09-30 involving a medication discontinued in error on 2025-08-15 for Resident R1.

No deficiencies were cited during the visit. The Licensing Program Analyst determined the incident requires further investigation. An exit interview was conducted with the General Manager.

The visit was complaint-related due to a medication error reported by the facility. The report states the resident's physician and responsible parties were notified. No deficiencies were cited during this visit.

The visit was an unannounced Case Management - Incident inspection triggered by an incident report received on 08/01/2025 regarding a physical altercation between two residents on 07/31/2025.

The investigation found that staff intervened during the altercation, no injuries were observed, residents were assessed, and responsible parties were notified. The facility is monitoring the involved residents and has implemented measures to prevent further incidents. No deficiencies were cited during the visit.

The complaint involved a physical altercation between Residents R1 and R2 on 07/31/2025. The incident was reported, no injuries were observed, and the facility is monitoring the residents involved.

An unannounced annual inspection was conducted as a required one-year visit to evaluate compliance with licensing requirements.

The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. The facility was well-maintained, with proper food storage, secure medication and cleaning product storage, functioning safety equipment, and complete resident and staff records.

The visit was an unannounced Case Management - Incident inspection conducted regarding an incident that occurred on 2025-05-27, following receipt of an Incident Report on 2025-05-28.

No deficiencies were cited during this visit. The Licensing Program Analyst determined that the case management requires additional review and information.

The visit was an unannounced Plan of Correction (POC) follow-up to review deficiencies cited on 2025-04-04 related to two elopements reported in December 2024.

The facility provided documentation of staff training on elopement and related topics conducted on 2025-04-16 and 2025-04-23. The Licensing Program Analyst cleared the previously cited deficiencies during this visit, and no new deficiencies were cited.

The visit was an unannounced Case Management-Incident inspection regarding two elopements that occurred on 12/8/2024 and 12/15/2024 involving residents R1 and R2.

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 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 inspection was conducted in response to a complaint alleging that the facility staff did not ensure that residents’ rooms are clean, safe, and sanitary at all times.

After interviews with staff, residents, and a tour of multiple resident rooms in both assisted living and memory care sections, the Department found the allegation to be unsubstantiated. Most staff and residents reported no issues with cleanliness, and the rooms observed were clean, safe, and sanitary.

The complaint alleged that residents’ rooms were often not cleaned properly, with issues such as feces in or on the toilet, trash on the floor, and beds not being made regularly. The investigation included interviews with staff and residents, and multiple room inspections. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced case management follow-up to investigate a medication error reported in an incident involving Resident R1 on 2025-02-27.

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 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 visit was conducted as a Case Management - Incident investigation following an incident report received on 3/5/2025 regarding bruising observed on Resident R1.

The investigation found that the discoloration on R1's neck was green dye transferred from necklaces worn during a Mardi Gras event, which was wiped away. Bruising under R1's left eye was observed with an unknown cause. The facility plans to increase monitoring and staff training on recognizing bruising and discoloration.

The visit was complaint-related due to an incident report of bruising on Resident R1. The bruising on the neck was determined to be dye transfer and not an injury, but bruising under the left eye was unexplained. The facility sought medical care and informed all responsible parties and the physician.

The visit was an unannounced Case Management-Incident inspection regarding two elopements that occurred on 12/8/2024 and 12/15/2024.

LPAs toured and tested exit doors related to the elopements, interviewed staff and the administrator, and requested additional documentation and security video footage. Due to insufficient information, the investigation requires further review.

The investigation was triggered by two elopements. Interviews were conducted with staff and the administrator, but one resident declined to be interviewed. Additional documentation and video footage were requested. The investigation remains open due to insufficient information.

The visit was an unannounced Case Management inspection to follow up on two incident reports involving two resident elopements from the facility.

The inspection found that 13 out of 13 alarmed exit doors were functioning properly. The investigation is ongoing due to insufficient information, requiring additional review.

The inspection was conducted as a complaint investigation following allegations that facility staff did not respond to emails of complaints from family members and that the facility lacked directors of health service and resident service to manage and supervise caregivers.

The investigation found no evidence to support the allegations. Interviews with staff, residents, and family members indicated that the facility responded to complaints and that the absence of two directors did not impact care and supervision. The complaint was unsubstantiated and no citations were issued.

The complaint was received on 2024-05-22 with allegations that staff did not respond to family member complaints and that the facility lacked directors to manage caregivers. The investigation included interviews with the administrator, staff, residents, and family members. The findings were unsubstantiated.

The inspection visit was conducted as an unannounced complaint investigation following allegations that staff do not provide proper assistance to residents in care.

The investigation included interviews with residents and staff and a review of records. No concerns were expressed by residents, and staff denied the allegations. The complaint was found to be unsubstantiated due to insufficient evidence.

The complaint alleged that staff do not provide proper assistance to residents in care. The investigation found the allegations unsubstantiated based on interviews and evidence gathered.

The visit was an unannounced complaint investigation conducted in response to multiple allegations regarding staff practices, including restrictions on medical professional visits without COVID testing, assistance with incontinence care, meal provision, and response times to call lights.

The investigation included interviews, observations, and record reviews. All allegations were found to be unsubstantiated as evidence and interviews did not corroborate the claims. Residents and staff denied the allegations, and records showed compliance with CDC guidelines and timely care.

The complaint investigation was triggered by allegations that staff were not allowing medical professionals or family visits without a 24-hour COVID test, not assisting residents with incontinence care timely, not feeding residents, and not responding promptly to call lights. The investigation found no preponderance of evidence to substantiate these allegations.

The visit was an unannounced complaint investigation conducted to address allegations that the facility was not following COVID-19 protocols, staff were not answering residents' call buttons timely, residents were not getting medications timely, and residents were not getting showers timely.

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 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 visit was an unannounced complaint investigation conducted in response to allegations that staff were not safeguarding residents' personal property and were not preventing residents from being victims of financial abuse by an unknown perpetrator.

The investigation involved interviews with residents and staff and a review of records. All interviewed residents and staff denied the allegations, and no evidence was found to corroborate the claims. The complaint allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated. Allegations included failure to safeguard residents' personal property and failure to prevent financial abuse. Interviews with 7 residents and 3 staff members, as well as record reviews, did not support the allegations.

The visit was an unannounced complaint investigation conducted in response to allegations that facility staff neglected to assist residents during falls and that the facility was not quarantining COVID-19 positive residents.

The investigation found no corroboration for the allegations after interviews with residents and staff and review of facility plans and records. Both allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was triggered by allegations of neglect in assisting residents during falls and failure to quarantine COVID-19 positive residents. The allegations were found to be unsubstantiated based on interviews with 7 residents and 3 staff members, review of the fall prevention plan and COVID-19 mitigation plan, and evidence collected during the investigation.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff neglect resulting in the death of a resident, failure to follow medication orders, failure to safeguard resident's personal belongings, and failure to maintain a comfortable temperature for residents.

The investigation found that although some allegations may have occurred or be valid, there was not a preponderance of evidence to prove any violation did or did not occur. The allegations were therefore unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff neglect leading to a resident's death, medication errors by staff, theft of resident's valuables, and inadequate temperature control. The facility took some corrective actions such as banning a resident assistant and providing portable air conditioners upon request, but no violations were substantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-14 regarding medication administration errors and delayed staff response to resident requests at Sunshine Villa Assisted Living and Memory Care.

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 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.

An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements at Sunshine Villa Assisted Living and Memory Care.

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 inspection was conducted as a case management incident visit following a notice received on 10/06/2023 that a resident (R1) left the facility without notice on 10/01/2023 and was returned the same day by the spouse.

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.

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.

The inspection was conducted as an unannounced case management investigation in response to an incident report regarding the elopement of a resident on 02/24/2023.

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.

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.

An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with licensing regulations.

The facility was found to be clean, well-maintained, and compliant with all regulations. No deficiencies were cited during the visit. Staff and most residents were vaccinated, and appropriate infection control measures were observed.

An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with facility regulations.

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 inspection was an unannounced complaint investigation visit triggered by allegations received on 11/25/2020 concerning resident falls, feeding, fluid intake, and incident reporting at Sunshine Villa Assisted Living and Memory Care.

The investigation included multiple visits, interviews with residents and staff, and review of resident records. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence proving the alleged violations occurred.

The complaint involved allegations that a resident sustained multiple falls, staff failed to ensure proper feeding and fluid intake, and failed to properly report an incident. The resident central to the complaint had been moved and later passed away. The investigation found no substantiation of the allegations.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not allowing resident access to a telephone.

The investigation included interviews with residents and staff, document reviews, and observations. The allegation was found to be unsubstantiated as evidence did not prove that residents were denied telephone access.

The complaint was received on 01/06/2021 and investigated through multiple visits and interviews. The allegation that the facility did not allow resident access to a telephone was unsubstantiated.

The inspection was an unannounced complaint investigation triggered by allegations of inadequate staffing and unmet resident care needs at Sunshine Villa Assisted Living and Memory Care.

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 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 visit was conducted to investigate complaints alleging that the facility retained residents with prohibited health conditions and that residents were not receiving proper medical attention.

The investigation included multiple visits, interviews with residents, staff, family members, and hospice nurses, and review of resident records. The allegations were found to be unsubstantiated or unfounded, with no evidence of prohibited health conditions or inadequate medical care. No deficiencies or citations were noted.

The complaint investigation was initiated due to allegations that the facility retained residents with prohibited health conditions and that residents were not receiving proper medical attention. After investigation, the allegation of prohibited health conditions was found to be unfounded, and the allegation of improper medical attention was found to be unsubstantiated.

The inspection was conducted as a complaint investigation following allegations that staff failed to clean a resident's room, provide clean bedding, left the resident in wet clothing for an extended time, and denied hospice resident visitors.

After multiple visits, interviews with residents, staff, and medical professionals, and observations, the investigation found the allegations to be unsubstantiated. Resident rooms and bedding appeared clean, residents were well groomed, and hospice visitation was allowed as per facility policy.

The complaint investigation was unsubstantiated. Allegations included failure to clean resident's room, failure to provide clean bedding, leaving resident in wet clothing, and denying hospice resident visitors. The investigation included four visits, interviews with 18 residents and 16 staff, and review of 9 resident records. No evidence supported the allegations.

The inspection was conducted as a complaint investigation following allegations that the facility failed to provide adequate food service and that residents were being barricaded in their rooms.

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.

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.