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Deficiency Records for Four Seasons Healthcare and Wellness Center, LP
View the most recent health deficiencies and inspection results for Four Seasons Healthcare and Wellness Center, LP. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Four Seasons Healthcare and Wellness Center, LP. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-03-26 | 2026-04-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2026-02-20 | 2026-03-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-02-20 | 2026-03-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-02-20 | 2026-03-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-02-11 | 2026-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-02-11 | 2026-03-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-02-11 | 2026-03-02 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2026-02-11 | 2026-03-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-01-09 | 2026-01-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-12-02 | 2026-01-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-12-23 | 2026-01-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-12-12 | 2025-12-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-12-04 | 2025-12-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-11-13 | 2025-11-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-11-13 | 2025-11-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-10-24 | 2025-10-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-10-24 | 2025-10-31 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2025-09-15 | 2025-09-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-08-22 | 2025-09-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-08-22 | 2025-09-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-07-02 | 2025-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-11 | 2025-06-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-06-11 | 2025-06-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-06-13 | 2025-06-27 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-04-25 | 2025-05-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-25 | 2025-05-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-04-25 | 2025-05-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-04-25 | 2025-05-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-04-25 | 2025-05-16 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2025-04-25 | 2025-05-16 | Y |
| Implement a program that monitors antibiotic use. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-04-25 | 2025-05-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-04-25 | 2025-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-04-25 | 2025-05-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-04-25 | 2025-05-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2025-04-25 | 2025-05-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2025-04-25 | 2025-05-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-04-25 | 2025-05-16 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-04-25 | 2025-05-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-04-25 | 2025-05-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2025-04-25 | 2025-05-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-04-03 | 2025-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-03 | 2025-04-22 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2025-03-13 | 2025-04-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-03-13 | 2025-04-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-13 | 2025-04-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-13 | 2025-04-04 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-03-13 | 2025-04-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-03-13 | 2025-04-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-02-11 | 2025-02-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-01-13 | 2025-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-13 | 2025-02-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-11-28 | 2024-12-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-12 | 2024-12-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-11-12 | 2024-11-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-08 | 2024-10-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-10-08 | 2024-10-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-12 | 2024-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-29 | 2024-08-14 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-07-11 | 2024-08-05 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-06-26 | 2024-07-23 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-05-03 | 2024-05-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-03 | 2024-05-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-03 | 2024-05-30 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-03 | 2024-05-30 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-05-03 | 2024-05-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-03 | 2024-05-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-03 | 2024-05-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-03 | 2024-05-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-03 | 2024-05-30 | Y |
| Dispose of garbage and refuse properly. | Health | 2024-05-03 | 2024-05-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-03 | 2024-05-30 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-03 | 2024-05-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-05-03 | 2024-05-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-03 | 2024-05-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-03 | 2024-05-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-03 | 2024-05-30 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-03 | 2024-05-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-03 | 2024-05-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-03 | 2024-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-09 | 2024-05-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-03 | 2024-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-03 | 2024-05-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-03 | 2024-05-23 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-05-03 | 2024-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-03 | 2024-05-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-03 | 2024-05-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-11 | 2024-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-04 | 2024-03-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-04 | 2024-03-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-04 | 2024-03-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-04 | 2024-03-18 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-01-12 | 2024-01-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-27 | 2023-12-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-27 | 2023-12-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-09 | 2023-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-09 | 2023-11-02 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-10-09 | 2023-11-02 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-10-09 | 2023-11-02 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-08-04 | 2023-08-11 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-08-13 | 2022-05-23 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-13 | 2021-09-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-13 | 2021-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-13 | 2021-09-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-13 | 2021-09-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-13 | 2021-09-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-13 | 2021-09-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-13 | 2021-09-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-13 | 2021-09-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-13 | 2021-09-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-13 | 2021-09-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-13 | 2021-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-09-07 | N |
| Provide activities to meet all resident's needs. | Health | 2021-08-13 | 2021-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-13 | 2021-09-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-13 | 2021-09-07 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-13 | 2021-09-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-13 | 2021-09-07 | N |