Four Seasons Rehabilitation & Care

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician responded to monthly medication regimen reviews (MMR) for 3 (#4, 5 and #21) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy for one (#1) of four residents reviewed for allegations of abuse. The administrator identified four allegations of abuse in the last six months.

Inspectors wroteBased on record review and interview, the facility failed to ensure MDS assessment accurately reflected the residents' status related to a GDR which was clinically contraindicated for one (#16) of five residents whose medications were reviewed. The administrator identified 44 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure OHCA was contacted when residents had serious mental illnesses for two (#11 and #29) of two residents reviewed for PASRR assessments. The DON identified 44 residents resided in the facility.

Inspectors wroteBased on record review, and interview, the facility failed to update a comprehensive care plan for three (#8, 11, and #29) of three sampled residents reviewed for revision of care plans. The facility failed to update care plans related to: a. pressure ulcers for Res #8, b. bed rails and low air mattress for Res #11, and c. schizoaffective disorder for Res #29. The administrator identified 44 residents who resided at the facility. Findings 1. Resident #8 was admitted on [DATE] with diagnoses of multiple sclerosis, overactive bladder, chronic pain, chronic kidney disease, and diabetes mellitus type II. A revised care plan, dated 09/18/23, documented skin was intact and without evidence of redness, irritation, maceration, or open areas. The care plan also documented the resident was at risk for pressure ulcers. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#16) of one sampled residents for assistance with bathing. The administrator identified 44 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper catheter bag placement to prevent urine back flow for one (#2) of one resident who was reviewed for catheters. The DON identified five residents who had catheters.

Inspectors wroteBased on record review and interview, the facility failed to ensure significant medication errors did not occur for one (#16) of five residents whose medications were reviewed. The administrator identified 44 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to follow the menu and make changes changes with the dietitian approval for the residents. The dietary manager identified 41 residents received meals prepared by the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store and distribute food in a sanitary manner for the residents. The dietary manager identified 41 residents who received meals from the kitchen and three residents who received nutrition via tube feeding.

Inspectors wroteBased on record review and interview, the facility failed to provide an ABN notice for one (#18) of three residents who were reviewed for beneficiary notices. The administrator identified 19 residents who were discharged from Medicare Part A services with days remaining.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation for one (#98) of one resident who was reviewed for allegations of abuse. The DON identified 11 allegations of abuse in past year.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change assessment after the resident had a change in condition for one (46) of 16 residents whose assessments were reviewed. The administrator identified 44 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a baseline care plan for one (#21) of 16 residents whose care plans were reviewed. The administrator identified 44 residents who resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to develop a comprehensive care plan related to a dialysis port for one (#38) of two residents reviewed for dialysis. The DON identified 44 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a resident was free from accident hazards for one (#11) of three sampled residents reviewed for accidents. The DON identified 44 residents resides in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a monthly medication regimen review for one (#8) of five residents reviewed for unnecessary medication. The administrator identified 44 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were obtained per physician orders for one (#8) of five sampled residents reviewed for unnecessary medications. The DON identified 44 residents that resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#11) of three residents reviewed for accident hazards. The DON identified 44 residents resides in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents' rights to privacy was provided during dining for five of (#1, 2, 3, 4, and #6) of six sampled resident's reviewed for privacy. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide the necessary ADL assistance to residents who were unable to carry out their own for four (#1, 2, 4, and #5) of six residents sampled for ADL (bathing) assistance. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the registered dietician's recommendations were implemented for one (#4) of three residents sampled for nutritional status. The Resident Census and Conditions of Residents form documented 49 residents who resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plans were updated or revised for four (#14, 17, 25 and #29) of seven care plans reviewed. The Resident Census and Conditions of Residents, dated 10/28/22, documented 48 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure two (#25 and #29) of 11 COVID-19 positive residents received physician ordered treatment in a timely manner. A Daily Census Report, dated 10/27/22, documented 11 of 48 residents resided on the Isolation Hall.

Inspectors wroteF698 Based on record review and interview, the facility failed to ensure a resident on dialysis received care and services for one (#24) of one sampled resident reviewed for dialysis. The facility failed to ensure: a. a physician's order was obtained for dialysis care, b. dialysis policy was followed The Resident Census and Conditions of Residents, dated 10/28/22, documented two residents were on dialysis services.