Four Seasons Assisted Living Center Llc

Based on observation, the licensee did not comply with the section cited above in 3 out of 5 taps delivering hot water did not measure within the required range which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 10 residents did not have a TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 staff had a 1st aid/CPR that expired in 10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by: Based on observation the licensee did not comply with the section cited above in two carts with cleaning supplies were left unattended and the laundry room was unlocked with laundry detergent and bleach which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in three (3) out of ten (10) resident bedrooms observed as they had over the counter and prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in four (4) out of ten (10) rooms observed as the they had disinfectants and cleaning solutions which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above as the facility's carpet is in disrepair with stains and a 5 foot rip, there is a hole on a wall, hole on residents bathroom door, rooms need to be cleaned, and there is a broken tile inside the elevator which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as R1 and R2 did not have their LIC 602 Physician's Report on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as R1 did not have their Tuberculosis results on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on medication audit, the licensee did not comply with the section cited above as R1, R3 and R4 did not have their medication on file which staff cannot assist with the self-administration of medication which poses/posed an immediate health, safety or personal rights risk to persons in care.

87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section above as various resident stated observing cockroaches additionally the LPA observed cockroaches in a R1's room which poses an potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as staff were observed to be wearing facemasks throughout the facility which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as one maintence staff was identified not be to asscoiated to the facility which poses an immediate health and safety risk to persons in care.

87629(a) Injections. The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as staff have administered insulin injections to residents, which poses an immediate health and safety risk to residents in care.

87468.1(a)(1) Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as it was communicated that residents were being yelled at in the facility by staff, which poses a potential personal rights risk to residents in care.

87468.2 (a)(4)... Personal Rights of Residents in All Facilities,... shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:Based on interviews, the licensee did not comply with the section cited above, as it was communicated that staff lack the sufficient skills to communicate in English, which poses a potential personal rights risk to residents in care.

(a)The pre-admission appraisal shall be updated.. as frequently as necessary.. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition..This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as twenty (20) out of twenty (20) residents’ files did not have a reappraisal, which poses an immediate health and safety risk to residents in care.

ADMISSION AGREEMENTS: Licensee’s failure to provided written notice to resident as stated in admission agreement. New rent increase became effective 01/01/2021. Resident was charged new rent increase as 01/01/2021. Resident received written notice on 05/14/2021.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by: Based on LPA observation, failed to fix ceiling with water damage which poses a potential safety risk to residents in care.

87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidenced by: Based on observation facility failed to properly store cleaniing solutions which poses an immediate health and safety risk to residents in care.

Maintenance and Operation: (c) All window screens shall be clean and maintained in good repair.This requirement was not met as evidenced by: Based on LPA observation, the facility failed to maintain resident #1 window screen which poses a potential safety risk to residents in care.