Inspection Reports for The Pines, A Merrill Gardens Community

The inspection was an unannounced 1-year annual inspection conducted to evaluate compliance with licensing requirements.

The inspection found no health or safety concerns in the facility, with all resident and staff files complete and current. No deficiencies were issued during the inspection.

The inspection visit was an unannounced complaint investigation triggered by an allegation of unlawful eviction received on 2025-06-19.

The investigation substantiated the allegation of unlawful eviction due to the licensee's failure to provide a complete eviction letter with required details such as effective date, specific facts, and required statements, posing a potential risk to residents.

The complaint was substantiated based on file review and interviews. The allegation of unlawful eviction was validated as the eviction letter was incomplete and did not meet regulatory requirements.

Licensing Program Analyst Sabrina Calzada arrived unannounced to conduct a required annual inspection of the facility.

The facility was toured including Assisted Living and Memory Care Units with no health or safety concerns observed. Resident files, medications, and staff files were reviewed and found complete and compliant. No deficiencies were issued during the inspection.

An unannounced complaint investigation was conducted following a complaint received on 2024-07-15 regarding staff not preventing a resident from being harmed by another resident.

The investigation found that multiple staff intervened quickly during the incident, and based on police and hospital records, no egregious injury was sustained. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not prevent a resident from being harmed by another resident resulting in injury. The allegation was found unsubstantiated after review of video surveillance, interviews, and medical records.

The visit was a case management inspection regarding an incident that occurred on 2024-08-23 involving a resident found injured outside the facility.

The resident was found in the parking lot with a rib fracture and UTI after leaving the facility unsupervised. The facility is following up with the resident's care team and has implemented 1:1 supervision during nighttime hours. No deficiencies were cited during the visit.

The investigation was triggered by an incident where resident R1 left the facility unsupervised and was found injured. The resident had been assessed as not a wander risk and oriented, with no wandering behavior noted in recent physician reports.

The inspection was conducted as a case management visit to obtain additional information regarding an incident report submitted about a missing pill of Norco from the medication cart on 2024-07-12.

The facility followed its medication protocols, including increased security measures implemented in May 2024. Despite interviews and investigation, the missing medication was not found, and no deficiencies were cited in this report.

The visit was triggered by a complaint related to a missing Norco pill. The investigation included interviews with staff and review of security footage, which was inconclusive. Staff member S1 resigned during the investigation. Resident R1 did not miss any doses. The complaint was not substantiated with definitive evidence.

The inspection was conducted as a case management follow-up on an incident involving missing medication tablets reported in May 2024.

The facility discovered 10 tablets of PRN Norco 5/325 mg missing from the medication room. An internal investigation was conducted, corrective actions were taken with involved staff, and new key control procedures and cameras were implemented. No further medication losses were reported.

The visit was triggered by a complaint regarding missing medication tablets. The investigation found that staff possibly kept unauthorized keys to the medication room. Corrective actions and preventive measures were implemented.

The inspection was conducted as a case management visit to obtain additional information regarding two incident reports recently submitted to the Department.

The facility responded immediately and appropriately to the incidents involving two residents, submitting timely incident reports. No deficiencies were issued in this report.

The inspection was triggered by two incidents: Resident 1 expressed suicidal ideation and was monitored with police and hospice involvement; Resident 2 fell, sustained injuries, was hospitalized briefly, and returned without follow-up appointments or new medications. Both incidents were handled appropriately.

An unannounced complaint investigation was conducted following a complaint received on 2024-04-09 regarding allegations that staff allowed a conserved resident to sign unauthorized forms and that staff were not properly trained.

The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred. Staff were aware of the resident's Power of Attorney but not all staff were clear on the resident's conservatorship status. A citation was issued for not following visitor sign-in/out policy.

The complaint alleged that staff allowed a conserved resident to sign unauthorized forms and that staff were not properly trained regarding conservatorship and document signing. The investigation concluded both allegations as unsubstantiated due to insufficient evidence.

The inspection was conducted as a case management visit following the facility reporting an infectious disease outbreak involving one resident and multiple staff members.

The facility took immediate precautionary measures including isolating affected individuals, use of PPE, increased disinfection, and staff training. No deficiencies were issued during this inspection.

The inspection was an unannounced complaint investigation triggered by a complaint received on 2024-04-09 regarding the facility's failure to follow its visitor policy.

The investigation substantiated that the facility did not follow its visitor policy, as evidenced by visitors not signing in or out as required, posing a potential health and safety risk to residents.

The complaint was substantiated based on video footage, visitor logs, and interviews showing that a male visitor did not sign in and a female visitor did not sign out on 4/8/24. The visitor log also showed 16 other visitors signed in and 5 who did not sign out.

The inspection was an unannounced case management visit to follow up on two incident reports recently submitted to the Department.

The inspection reviewed two incidents: one involving a resident sent to the ER due to difficulty removing an eye contact lens, and another involving a resident found intoxicated and sent to the ER, who has since transferred to a skilled nursing facility. The Administrator discussed plans to obtain a doctor's order for a limited daily alcohol amount and emphasized timely incident report submission.

The visit was an unannounced case management follow-up on a prior complaint investigation (#59-AS-20230804135453) to assess compliance and facility conditions.

No deficiencies were cited during the inspection. The Licensing Program Analyst toured the memory care unit and observed that a resident room was unlocked and accessible from both doors.

The visit was a follow-up on complaint investigation #59-AS-20230804135453.

Unannounced complaint investigation visit conducted due to allegations that staff did not ensure resident's nail care needs were met and that staff did not allow resident access to personal items.

Both allegations were investigated through interviews, documentation review, and observations. The complaint regarding nail care was found to be unfounded as podiatry care was documented and the resident received nail care. The allegation about restricting access to personal items was also found to be unfounded due to the resident's behavior of throwing items away and the facility's measures to protect belongings.

The complaint investigation was triggered by allegations that staff did not ensure resident's nail care needs were met and restricted resident access to personal items. Both allegations were found to be unfounded after investigation.

The inspection was an unannounced annual inspection conducted to ensure the health and safety of residents in care at the facility.

No deficiencies were cited during the inspection. The Licensing Program Analyst toured multiple areas of the facility, reviewed resident and staff files, and found no immediate health, safety, or personal rights violations.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility dishwasher was in disrepair and staff were not properly cleaning.

The Licensing Program Analyst toured the kitchen and facility, found the kitchen clean and sanitary, observed manual washing procedures, and confirmed the dishwasher was broken but a replacement had been ordered. The facility was clean and housekeeping was active. The allegations were found to be unfounded.

The complaint investigation was unannounced and based on allegations regarding dishwasher disrepair and improper cleaning by staff. After investigation, the allegations were determined to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-12 alleging the facility did not conduct pre-admission appraisals, denied visitation, phone access, mail receipt, and privacy to residents.

The investigation found all allegations to be unfounded after reviewing records, interviewing residents, staff, and witnesses. The facility conducted pre-admission appraisals, residents received visitation and privacy, had mail forwarded to authorized representatives, and were not denied phone access.

Complaint control number 25-AS-20220712132307 involved multiple allegations including failure to conduct pre-admission appraisals, denial of visitation, phone access, mail receipt, and privacy. All allegations were found to be unfounded.

The visit was an unannounced case management visit conducted to review deficiencies related to a medication error reported by the facility.

The facility failed to provide a resident (R1) with their prescribed Donepezil medication from February 1, 2023 through May 20, 2023 due to a medication technician inputting a discontinue order in error. The medication error was reported to the resident's physician and responsible party, and training was provided to staff as a result.

The visit was conducted as a complaint investigation due to a medication administration error involving resident R1, who was administered discontinued medications along with new medications, resulting in hypoglycemia and hospitalization with ICU admission.

The facility failed to follow its medication administration process, leading to a medication error that caused serious bodily injury to resident R1. Specifically, staff did not discontinue R1's discontinued medications on the MAR and failed to perform a second check comparing medication orders before administration.

During the complaint investigation, it was substantiated that facility staff administered two discontinued medications along with two newly ordered medications to resident R1, causing hypoglycemia and hospitalization with ICU admission.

An unannounced complaint investigation was conducted due to an allegation that facility staff failed to follow medication orders leading to a resident's death.

The investigation found that two medications were not discontinued as ordered, and the resident was administered discontinued medications. However, based on document review and interviews, there was no evidence that this violation contributed to the resident's death, and the allegation was unsubstantiated.

The complaint alleged that facility staff failed to follow medication orders leading to the death of Resident 1. The allegation was unsubstantiated after investigation.

The inspection visit was an unannounced case management visit conducted to review an incident involving a resident who had a fall and subsequent injury.

The Licensing Program Analyst found no deficiencies during the inspection. The resident who fell was sent to the emergency room, diagnosed with a lumbar spinal fracture, received medication, and has not had a reoccurring fall.

This was an unannounced annual inspection visit conducted as a required one-year evaluation of the facility.

The Licensing Program Analyst observed staff compliance with mask-wearing protocols and toured the facility with key staff. The facility includes assisted living and memory care units with various apartment types and common areas. No deficiencies were cited during this visit.

An unannounced complaint investigation was conducted in response to allegations that the facility was refusing resident visitation and calls, and not assisting a resident with glasses and hearing aid daily.

The investigation substantiated the allegations that the facility restricted visitation without prior notice and failed to assist a resident with their hearing aid as prescribed, posing potential health and safety risks to residents in care.

The complaint was substantiated based on evidence that the facility required visitors to contact the resident's Power of Attorney prior to visitation and failed to assist the resident with hearing aid use as prescribed.

An unannounced complaint investigation visit was conducted in response to an allegation that the facility was restricting visits.

The investigation found the allegation to be substantiated based on observations and interviews, confirming that the facility had a protocol requiring visitors to contact the resident's Power of Attorney prior to visitation, which was later rescinded. Despite substantiation, no new citation was issued as the facility had been cited for a similar allegation on the same day in a different complaint.

The complaint was substantiated, meaning the allegation was valid based on the preponderance of evidence. The allegation involved the facility restricting visits by requiring visitors to notify the resident's Power of Attorney before visitation. The facility had been previously cited for a similar issue.

The visit was an unannounced complaint investigation regarding an allegation of illegal eviction received on 01/25/2022.

The investigation found that the facility did not issue a written eviction notice to resident R1, and the complaint was determined to be unfounded. The resident was sent to the hospital due to a change in condition and was subsequently placed in a new facility due to increased care needs and safety concerns.

The complaint alleged illegal eviction of resident R1. The investigation included record reviews and interviews, concluding that no eviction notice was given and the complaint was unfounded.

The visit was an unannounced complaint investigation triggered by a complaint received on 09/13/2021 alleging the facility did not obtain all required admission documentation prior to admitting residents.

The investigation found that the facility had obtained all required admission documentation for residents R1 and R2 at the time of admission. The complaint was determined to be unfounded.

The complaint alleged the facility accepted residents R1 and R2 without proper admission documentation. The complaint was investigated and found to be unfounded.

The visit was an unannounced required 1-year inspection conducted to evaluate compliance with licensing regulations and COVID-19 protocols.

No deficiencies were cited during the inspection. Staff and resident files were reviewed and found to be in compliance with required documentation and training. Common areas were clean and in good repair.

The inspection visit was conducted to investigate a complaint of neglect of a resident received on 2021-03-11.

The investigation reviewed medical reports, nursing notes, care plans, staff schedules, and conducted staff interviews. The allegation of neglect was found to be unsubstantiated due to insufficient evidence.

The complaint allegation of neglect of a resident was investigated and found to be unsubstantiated.