Deficiency Records for Four Seasons Healthcare and Wellness Center, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Four Seasons Healthcare and Wellness Center, LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-24 | 2023-04-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-24 | 2022-08-12 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-24 | 2022-08-12 | Y |
| 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 | 2022-07-24 | 2022-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-06-10 | 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 |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-02-08 | 2022-02-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-04 | 2022-01-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-27 | 2022-01-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-13 | 2021-09-07 | 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| Provide activities to meet all resident's needs. | 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 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 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 safe, appropriate pain management for a resident who requires such services. | 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 |
| 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 |
| Ensure each resident?s drug regimen must be free from unnecessary 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 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 |
| 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 |
| Provide and implement an infection prevention and control program. | 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 |
| Have properly located and lighted "Exit" signs. | 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 |
| 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 |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Install an approved automatic sprinkler system. | 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 |
| 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 |
| Install corridor and hallway doors that block smoke. | 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 |
| Have properly installed electrical wiring and gas equipment. | 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 generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 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 proper medical gas storage and administration areas. | Fire Safety | 2021-08-13 | 2021-09-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-24 | 2020-03-24 | 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 | 2020-02-24 | 2020-03-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-24 | 2020-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-24 | 2020-03-24 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-24 | 2020-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-24 | 2020-03-24 | 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 | 2020-02-24 | 2020-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-24 | 2020-03-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-24 | 2020-03-24 | 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 | 2020-02-24 | 2020-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-24 | 2020-03-24 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-02-24 | 2020-03-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-24 | 2020-03-24 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2020-02-24 | 2020-03-24 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-20 | 2020-03-24 | 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 | 2020-02-20 | 2020-03-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2020-02-20 | 2020-03-24 | 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 | 2019-02-26 | 2019-04-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-26 | 2019-04-30 | 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 | 2019-02-26 | 2019-04-30 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-26 | 2019-04-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-26 | 2019-04-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-26 | 2019-04-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-26 | 2019-04-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-26 | 2019-04-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-02-26 | 2019-04-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-26 | 2019-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-26 | 2019-04-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-26 | 2019-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-26 | 2019-04-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-02-27 | 2019-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-27 | 2019-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-27 | 2019-03-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-02-26 | Not Fixed | N |
