Four Seasons Care Home

87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by; Based on facility's observations and staff's interviews, licensee/ administrator is not complying with applicable laws and regulations resulting in deficiencies and repeat violations which poses a potential health and safety risks to residents in care.

Based on staff's interview and record review, the licensee did not comply with the section cited above as facility was not doing required fire and disaster quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.

False Claims - No licensee, officer or employee of a license shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This required is not met as evidenced by ... Although the Administrator has a current Admin certificate #7005884740 8/28/2024-8/27/2026; the Administrator certificate POSTED has the following altered information: #6019660740 8/28/2022-8/27/2025. The expiration in this case was altered to a later date. This poses a potential healthy and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above as staff, S1 has records of on boarding and annual training which poses/posed a 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 was pre pouring residents medications for 7 days in advance which poses an immediate 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 staff ,S1 does not have required health screening on file which poses/posed a 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 multiple food items were found with expired dates which poses/posed a potential health, safety or personal rights risk to persons in care.

87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by; Based on record review and staff's interviews, facility does not have a qualified Administrator which poses a potential health and safety risks to residents in care.

Based on staff's interview and record review, the licensee did not comply with the section cited above as facility was Not doing required fire and disaster quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on medications count, record review and staff's interviews, it was noted that for resident, R2- No update medications order list for resident R2 for 2024 in thier file, Expired Eye Drops x4 bottles, Aspirin 81mg (wrong medication), Alendronate Sodium Tablet-70mg-1tablet every friday with start date 06/17/24, sholud have 5 tablets out of 12 but count was 8 tablets ON HAND and FOR R1- Bupropion HCL 150MG-1 tablet twice a day with start date 05/21/24,180 tablets filled 05/21/24, count was OVER 69 tablets ,Simvastin 20 mg, 100 tablets filled on 05/17/24, start date- 05/17/24, 19 tablets extra during today's count which poses an immediate health, safety or personal rights risk to persons in care.

Based on observations in pantry and kittchen area, LPA found mulpile food items with expired dates which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observations, facility has one fire extinguisher which was last serviced in 2022 which poses a potential health, safety or personal rights risk to persons in care.

LPA observed that facility's laundry room has no lock on the door and has disinfectants, cleaning solutions which were accessible to residents and poses a potential health and safety risks to residents in care.

Based on staff's interview and record review, the licensee did not comply with the section cited above as LPA found , Missing Consent Form, Pre-Admission Appraisal, Personal Belongings form, Personal Rights Form for Resident,R1 file and Missing Consent Form, Personal Belongings form, Personal Rights Form for Resident,R2 file which poses/posed a potential health, safety or personal rights risk to persons in care.

87406(g)- Administrator Certification Requirements. Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidence by; The administrator certificate for Ioan Nagy expired on 08/07/2020 (#6019660740) and was not put in for renewal till date (08/29/23). This is a potential risk to the health and safety of the residents in care.

During file review, LPA observed that S2 file missing training for above section(s) as required which poses a potential health risks to residents in care.

During file review, LPA observed that S2 file missing annual training as required which poses a potential health risks to residents in care.

During file review, LPA observed that S2 file missing LIC501,LIC503,TB test ,LIC9052 as required which poses a potential health risks to residents in care.

During file review for R2, LPA observed that R2 file missing pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

During annual inspection on 08/04/22, LPA found that facility administrator has expired administartor certificate- Ioan Nagy (#6019660740, 08/07/20)