A list of the most recent deficiencies for Seasons Healthcare. 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? |
|---|---|---|---|---|
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-20 | 2023-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-07-20 | 2023-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-08 | 2023-08-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-20 | 2023-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-08-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-08 | 2023-08-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-08 | 2023-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-20 | 2023-07-26 | 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 | 2023-07-20 | 2023-07-21 | 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 | 2023-07-20 | 2023-07-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-28 | 2023-03-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-12 | 2022-06-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-12 | 2022-06-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-12 | 2022-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-12 | 2022-06-14 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-12 | 2022-06-14 | 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 | 2022-05-12 | 2022-06-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-12 | 2022-06-13 | 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 | 2022-05-12 | 2022-06-13 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-12 | 2022-06-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-12 | 2022-06-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-12 | 2022-06-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-12 | 2021-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-12 | 2021-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-09 | 2020-02-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-09 | 2020-02-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-09 | 2020-02-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-09 | 2020-02-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-09 | 2020-02-10 | 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 | 2020-01-09 | 2020-02-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-09 | 2020-02-10 | 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 | 2020-01-09 | 2020-02-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-09 | 2020-02-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-09 | 2020-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-09 | 2020-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-07 | 2020-02-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-07 | 2020-02-06 | N |
