The Villa

Resident A has not been administered medication in accordance with physician orders since May 2005. Review of MAR showed blank entries for specific dates in May 2025 and inability to determine if orders were received timely.

Clean and soiled linen closets contained non-linen items (boxes, equipment, etc.), and soiled linens were found near clean linens in the laundry room, posing a cross-contamination risk.

Multiple food items in the employee lounge and various kitchenettes were found unlabeled with appropriate open dates.

Dishwasher sanitization logs showed multiple incomplete or blank entries for sanitization temperatures.

Medication bottles were observed sitting unsecured on the counter of the medication station, easily accessible to anyone in the facility.

Multiple garbage or rubbish containers in various areas (assisted living, memory care, laundry, kitchens) were found without tight-fitting lids.

Hazardous and toxic chemicals and sharp items were stored in unlocked drawers, cabinets, and common areas, making them accessible to residents.

Resident D was left soiled for 3 days before staff changed her, resulting in a stage 1 pressure ulcer.