Five Star Assisted Living Corp

87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case… This requirement was not met as evidence by: records reviewed, the licensee did not comply with the section cited above in that review of incident reports provided to the Department are not being completed. LPA reviewed incident reports for R1’s death. Death reports were not submitted by the Licensee from the period of 3/25/25 through 2/2/26. R1 passed on 7/28/25. This poses a potential health safety and or personal rights risk to residents in care.

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met as evidence by: review of records and interviews completed. The licensee did not comply with the section cited above in that R1 passed on 7/28/25 and their belongings were removed from the facility on 7/29/25. Licensee did not provide a refund for the 2 days of the month that the resident did not reside at the facility in the amount of $322.58. This poses a potential health safety and or personal rights risk to residents in care.

Resident access to hazardous items with safety review

Based on records reviewed and LPA observation, the licensee did not comply with the section cited above in 2 hair iron/straighteners were observed in an unlocked bathroom drawers. Nutritional supplements (ensure) observed unlocked and accessible to residents in the food pantry. 1 of 3 resident files reviewed indicated these items would be a safety risk to resident(s) in care. This poses a potential health, safety or personal rights risk to persons in care.

Require fire clearance before non-temporary bedridden admission

Based on LPA observation, the licensee did not comply with the section cited above in facility having 2 bedridden residents. Review of resident LIC 602's indicated bedridden for 2 of 6 residents. Facility is only approved for 1 bedridden resident. This poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that pool fence observed with open area on left side not completely surrounding pool, in need of repair. This poses a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on LPA observation, the licensee did not comply with the section cited above in air vents in Bathroom #2 is rusted/dirty and in need of cleaning/replacement. Bathroom #2 baseboard in need of repair/replacement. Bathroom #2 light switch broken and in need of repair. Fence on right side leaning and in need of repair. Debris observed in pool area in need of removal. Concrete walkway in back of house observed with a lip (possible tripping hazard) in need of repair. Bedroom #6 observed with a broken window in need of repair. This poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA observation, the licensee did not comply with the section cited above in chemicals, sharps and items posing a danger observed unlocked and accessible throughout the facility. This poses a potential health, safety or personal rights risk to persons in care.

Acceptance obligations tied to pre-admission appraisal needs

87464 Basic Services: (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident...the facility shall be responsible for meeting the resident's needs... This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure facility staff could meet the needs of one out of six residents, which posed a potential health, safety and personal rights risk to persons in care.