Deficiency Records for Four Seasons Rehabilitation and Care
Updated as of July 01, 2021
This is not the most recent data for Four Seasons Rehabilitation and Care. For the most recent information, click here.
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 and implement an infection prevention and control program. | Health | 2021-01-19 | 2021-02-19 | 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 | 2020-06-09 | 2020-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-15 | 2020-02-06 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-01-15 | 2020-02-06 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-01-15 | 2020-02-06 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-19 | 2019-12-09 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-19 | 2019-12-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-19 | 2019-12-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-19 | 2019-12-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-19 | 2019-12-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-19 | 2019-12-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-19 | 2019-12-09 | Y |
| 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 | 2019-11-19 | 2019-12-09 | 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 | 2019-11-19 | 2019-12-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-13 | 2019-08-26 | Y |
| 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 | 2019-08-13 | 2019-08-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-08-13 | 2019-08-26 | Y |
| 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 |
| 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 |
| 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 |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-19 | 2019-01-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-19 | 2019-01-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-19 | 2019-01-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-19 | 2018-12-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-19 | 2018-12-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-11-19 | 2018-12-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-19 | 2018-12-06 | Y |
| 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 | 2018-11-19 | 2018-12-06 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-11-19 | 2018-12-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-19 | 2018-12-06 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-05-15 | 2018-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-15 | 2018-06-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-15 | 2018-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-15 | 2018-06-14 | 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 | 2018-05-15 | 2018-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-15 | 2018-06-14 | 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 | 2018-05-15 | 2018-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-15 | 2018-06-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-15 | 2018-06-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-05-15 | 2018-06-14 | 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 | 2018-05-15 | 2018-06-14 | 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 | 2018-05-15 | 2018-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-15 | 2018-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-15 | 2018-06-14 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2018-05-15 | 2018-06-14 | 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 | 2017-03-29 | 2017-05-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-03-29 | 2017-05-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-03-29 | 2017-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-03-29 | 2017-05-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2017-03-29 | 2017-05-15 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-04-03 | 2017-05-15 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-03 | 2017-05-15 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-03 | 2017-05-15 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-04-03 | 2017-05-15 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-04-03 | 2017-05-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-03 | 2017-05-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-04-03 | 2017-05-15 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-04-03 | 2017-05-15 | N |
