Four Seasons Health Care Inc

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to notify the physician of a change in condition for 2 of 3 sampled residents (Resident #2 and #3) with a decline in skin integrity. Failure to promptly notify the physician or provider of the change in skin condition limited their ability to make informed decisions regarding the residents' medical care.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to provide adequate supervision for 1 of 1 sampled resident (Resident #3) who sustained an injury during a sit-to-stand mechanical lift transfer. Failure to ensure supervision while transporting through a doorway with a stand lift resulted in a skin tear and placed the resident at risk of experiencing pain/discomfort and a more serious injury.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, review of the Minimum Data Set (MDS) validation reports in Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQies), and staff interview, the facility failed to ensure timely electronic data submission of required assessments for 8 of 13 sampled residents (Resident #3, #4, #8, #9, #15, #18, #19, and #22) with late assessments. Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 5 sampled resident (Resident #18) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 13 sampled residents (Resident #3, #5, and #22). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, review of manufacturer's instructions for use, and staff interview, the facility failed to ensure staff followed standards of care for 1 of 1 resident (Resident #3) observed for insulin administration. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction.

Inspectors wroteBased on record review, review of facility policy, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview, the facility failed to offer the pneumococcal vaccine to 2 of 5 residents (Resident #4 and #22) reviewed for immunization status. Failure to offer the recommended pneumococcal conjugate vaccines (PCV) and pneumococcal polysaccharide vaccine (PPSV) to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contract pneumonia and spread the infection to other residents, visitors, and staff.

Inspectors wroteBased on observation, review of facility policy, record review, and staff interviews, the facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for 2 of 2 sampled residents (Resident #1 and #2) observed during mechanical lift transfers. Failure to assess for and utilize the correct sling sizes for residents during full body mechanical lift transfers placed the residents at risk for falls and/or injuries.

Inspectors wroteBased on review of a FRI, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident (Resident #1). Failure to protect Resident #2 from sexual abuse may result in psychosocial harm and mental and emotional distress.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 closed record resident (Resident #28) reviewed. Failure to assess, monitor and implement interventions in response to Resident #28's decline in condition may have contributed to the resident's death.

Inspectors wroteBased on review of the State Agency (SA) facility files, review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of facility policy, survey findings, and staff interview, the facility failed to develop a QAPI process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment in multiple areas of the facility (supply room, laundry room, oxygen storage room, and resident rooms) observed during survey. Failure to maintain a safe, clean, comfortable, and sanitary environment and keep resident care equipment clean and properly stored does not provide a homelike area for residents or promote quality of life.

Inspectors wroteBased on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 8 of 12 sampled residents (Resident #3, #4, #6, #11, #15, #20, #23, and #24). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on confidential resident interviews, the facility failed to ensure the availability of sufficient nursing staff to respond to residents' needs for 3 of 3 confidential residents (Residents A, B, and C). Failure to provide sufficient staffing for resident needs/assistance may negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to prepare and store food in a sanitary manner in 1 of 1 kitchen and 1 of 2 resident refrigerators (main lobby). Failure to ensure proper concentration of sanitizer solution, apply an identifying label and an open date on food items brought into the facility, and ensure cleanliness in a resident refrigerator has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written bed hold notice at the time of the transfer or if an emergency, within 24 hours for 1 of 2 sampled residents (Resident #23) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice in a timely manner does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #8) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with the resident's needs.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 12 sampled residents (Resident #4, #10, and #23). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 resident (Resident #14) observed receiving a topical medication. Failure to administer topical medications according to physician orders may result in adverse outcomes for the resident.

Inspectors wrote1. Based on observation, record review, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 3 sampled residents (Resident #11) observed during a gait belt transfer. Failure to utilize a gait belt during transfers placed the resident at risk for falls and/or injury.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure medications were properly dated, expired medications are discarded, and medications were securely stored in 2 of 3 storage areas (treatment cart and medication room). Failure to store all medications securely may result in unauthorized access to medications (treatment cart) and failure to dispose of expired medications and date an opened multi-dose vial (medication room) may result in reduced efficacy of the medications.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #11) observed during wound cares. Failure to practice infection control standards related to enhanced barrier precautions, has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure posting of accurate and complete staffing information on 3 of 4 days of survey (October 27-29, 2024). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to implement a baseline care plan within 48 hours of admission for 1 of 1 new admission (Resident #130). Failure to develop and implement a baseline care plan in a timely manner may result in care that is inconsistent with residents' needs.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to review and revise care plans to reflect residents' current status for 3 of 13 sampled residents (Resident #12, #14, and #15). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, review of facility policy and staff interview, the facility failed to follow professional standards of practice for 1 of 1 insulin administration observed during medication administration. Failure to properly prepare an insulin pen may result in a resident receiving an inaccurate dose of insulin.

Inspectors wroteBased on observation, review of facility policy, record review, and staff and resident interview, the facility failed to provide individualized, meaningful activities for 1 of 13 sampled residents (Resident #12) dependent on staff for activity participation. Failure to implement an individualized activity program to meet the interests/needs of dependent residents may have a negative effect on their overall well-being.

Inspectors wroteBased on record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 sampled resident (Resident #14) with a transfer to the emergency room (ER) for a change in health status. Failure to monitor and assess the resident's condition on an on-going basis may have resulted in worsening respiratory symptoms and a delay in treatment.