Deficiency Records for Four Seasons Rehabilitation and Care
Updated as of March 01, 2024
A list of the most recent deficiencies for Four Seasons Rehabilitation and Care. 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 and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-11 | 2023-11-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-11 | 2023-11-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-11 | 2023-08-21 | 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 | 2023-05-24 | 2023-07-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-24 | 2023-07-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-24 | 2023-07-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-28 | 2022-11-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-28 | 2022-11-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-28 | 2022-11-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-25 | 2022-11-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-25 | 2022-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-10 | 2021-07-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-06-10 | 2021-07-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-10 | 2021-07-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-06-10 | 2021-07-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-15 | 2019-05-10 | 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 | 2019-04-15 | 2019-05-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-15 | 2019-05-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-04-15 | 2019-05-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-15 | 2019-05-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-15 | 2019-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-15 | 2019-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-15 | 2019-05-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-15 | 2019-05-10 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-04-15 | 2019-05-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-04-15 | 2019-05-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-04-15 | 2019-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-15 | 2019-05-10 | 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 | 2019-04-15 | 2019-05-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-15 | 2019-05-10 | 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 | 2019-04-15 | 2019-05-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-15 | 2019-05-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-15 | 2019-05-10 | 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 | 2019-04-15 | 2019-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-15 | 2019-05-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-10 | 2019-05-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-10 | 2019-05-10 | 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 | 2019-04-10 | 2019-05-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-10 | 2019-05-10 | N |
