Seasons Healthcare and Rehabilitation

Inspectors wroteBased on observation, interview, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff wore hair restraints in the dietary department to prevent potential contamination of food and food preparation equipment. This had the potential to affect 42 of 42 residents who received meals from the dietary department.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 (Resident #143) of 1 newly admitted resident reviewed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that addressed all triggered care areas from the Minimum Data Set (MDS) for 1 (Resident #4) of 13 sampled residents.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure as-needed (PRN) orders for psychotropic medications specified the duration of use and the residents' records reflected documentation of the rationale for use beyond 14 days for 2 (Resident #11 and Resident #23) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the drug regimen of each resident was reviewed monthly by a licensed pharmacist and that any identified irregularities were reported to the attending physician and documented what, if any, action had been taken to address it. In addition, the facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, for 3 out of 27 sampled residents, residents that had irregularities identified by the pharmacist were not acted upon by the attending physician in a timely manner. [...]

Inspectors wrote3. Resident 27 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes with neuropathic arthropathy, major depressive disorder, anxiety disorder, bipolar disorder, epilepsy, history of poliomyelitis, intellectual disabilities, and gastro-esophageal reflux disease. Resident 27's medical record was reviewed on 1/24/23. A review of resident 27's physician orders revealed the following: a. Effexor extended release (XR) capsule 150 MG, give 1 capsule by mouth every day shift related to major depressive disorder. The order was initiated on 6/4/21. b. Zyprexa tablet 5 MG, give 1 tablet by mouth every day shift related to bipolar disorder. The order was initiated on 2/23/22. [...]

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure prompt efforts were taken by the facility to resolve grievances the residents may have had. In addition, the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision. Specifically, for 1 out of 27 sampled residents, the facility did not document the grievance of a resident who stated an item of her clothing went missing, and a prompt resolution to the grievance was not documented or followed up on by the facility. In addition, there were no grievances documented for the previous year. Resident identifier: 38.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, for 1 out of 27 sampled residents, a resident with a hand contracture was not being provided the ordered device to hold in the contracted hand during the day for comfort and prevention. Resident identifier: 10.

Inspectors wroteBased on interview and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 27 sampled residents, a resident that had uncontrolled pain was not evaluated for increased pain medication needs by the Medical Director (MD). Resident identifier: 15.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, for 1 out of 27 sampled residents, a resident's physician visits for the first 90 days after admission were not completed timely by the facility Medical Director (MD) or the hospice physician. Resident identifier: 15.

Inspectors wroteBased on observation and interview, it was determined, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants, and the resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, the nurse staffing information was not completed and readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 1 out of 27 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with an antibiotic that was based off of a urinalysis (UA) and culture and sensitivity (C&S) that was collected three months prior. Resident identifier: 1.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Specifically, the full survey results were not available to residents.

Inspectors wroteBased on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility the director of food services was did not meet the requirements to serve as the director of food and nutrition services.

Inspectors wroteBased on observation and interview it was determined, for 4 of 37 sample residents, that the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained that the food was not palatable and the test tray was not visibly attractive or palatable. Resident identifiers: 8, 33, 35 and 41.

Inspectors wroteBased on interview and record review it was determined, for 1 of 37 sample residents, that the facility did not implement written policies and procedures that prohibited and prevented abuse. Specifically, staff did not investigate or follow up after a resident was yelled at by another resident in the dining room. In addition, the resident hit the table while yelling at the resident. Resident identifier: 30.

Inspectors wroteBased on interview and record review it was determined, for 1 of 37 sample residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 36.