Mills Estate Villa

Keep prescriptions in original containers

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on observation and interview, at 11:15AM, during the tour of facility with the administrator, LPA observed medications for resident #1 (R1), resident #2 (R2), resident #3 (R3), resident #4 (R4) and resident #5 (R5) were removed from its original container and poured into covered small plastic cups with resident's room number on it. The med tech/shift manager Staff #1 (S1) stated that some of those residents were discharged therefore the medications were for destruction and S1 did not know the reason why those medications were removed from its original containers. The administrator observed and acknowledged that the medications should not have been removed from its original containers even for destruction which poses an immediate health, safety or personal rights risk to persons in care.

Keep bath, laundry and kitchen floors clean

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the kitchen floor underneath the dishwater sinks appeared to be black with grease stains which poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident #1 has a bottle of Refresh eardrops at the bedside table which poses an immediate health, safety or personal rights risk to persons in care.

Keep prescriptions in original containers

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the medication cart consisted of little plastic containers with medications stored in a few big plastic boxes for the PM shift, HS shift, and AM shift for the following day which poses an immediate health, safety or personal rights risk to persons in care.

Food quality controls and rejected damaged goods

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed an opened carton of egg nog with an expiration date of January 11, 2025 which poses an immediate health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 3 out of 5 residents have bedrails without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident #2 (R2) with oxygen in the dining room with other residents and there was no "No Smoking - Oxygen in Use" sign around the area which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 5 residents who has a diagnosis of Dementia did not have an updated Medical Assessment (LIC 602) which poses/posed a potential health, safety or personal rights risk to persons in care.