Seasons Rehab and Healthcare Center

Inspectors wroteBased on interview and record review, the administration of the facility failed to safeguard the medication administration of each resident. The administration failed to provide Certified Medication Technician (CMT) A his/her own sign in to pass medications once notified the sign on was not working. CMT A used Licensed Practical Nurse (LPN) A's sign in to pass medications to the facility residents. This has the potential to affect all residents. The facility census was 74 residents. Review of the facility undated Onboarding Standard Operating Procedure showed:-Interview applicant. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff-maintained documentation of medications as provided on the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for eight sampled residents ( Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9), when Certified Medication Technician (CMT) A used Licensed Practical Nurse (LPN) A's electronic sign in when he/she administered resident's medications for three months for eight of the nine sampled residents. The facility census was 74 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift in locations throughout the facility for view by residents, family members and visitors. The facility census was 74 residents. Record review of the facility Staffing, Schedule and Postings policy dated 10/24/2022 showed: -The facility would post the current date, the total number and the actual hours worked by licensed (RNs and LPNs) and unlicensed (CNAs) nursing staff directly responsible for resident care per shift, and the facility resident census. 1. Record review of the Staffing Ratio and Census Reports dated 12/27/24 through 1/27/25 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Residents #40 and #55) out of three sampled residents, who were notified their Medicare Part A coverage would likely end and had benefit days remaining, were provided the Quality Improvement Organization (QIO) contact name and toll free phone number on their Notice of Medicare Non-Coverage (NOMNC), Centers for Medicare (CMS)-10123 form. On 1/31/25 the Administrator was notified of the past non-compliance which took place for a period of months that started on or before 7/9/24 and went through 12/31/24. On 1/2/25 the Social Services Director was given an updated Form CMS-10123 containing the QIO contact name and toll-free number so residents could appeal the decision to end services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the needs of two sampled residents (Residents #49 and #176) who didn't like to go to group activities and were dependent upon staff to provide activities for mental, physical, and psychosocial stimulation out of 18 sampled residents. Additionally, the facility failed to ensure there was a way to easily access daily activity participation over time. The facility census was 74 residents. Review of the facility's Activities Program policy, revised 10/24/22, showed: -The purpose of the policy was to encourage resident participation to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable residents to maintain the highest attainable social, physical, and emotional functioning. [...]

Inspectors wroteBased on interview and record review, the facility failed to document behaviors and develop a care plan that included target behaviors (specific behaviors of the resident), and relevant non-pharmacological approaches for one sampled resident (Residents #49) who was prescribed a psychotropic medication (a drug that affects brain activities associated with mental processes and behaviors). The facility census was 74 residents. Review of the facility's Behavior Management policy, undated, showed key components of behavior management included: -Identifying residents whose behaviors may pose a risk to self or others. -Develop individualized and practical care strategies based on assessed needs. -Implement a behavior management program. -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including effectiveness of psychoactive drugs. [...]

Inspectors wroteBased on interview, and record review, the facility failed to assess a resident who had fallen before moving him/her and did not call Emergency Medical Services (EMS) in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 77 residents. The Administrator was notified on 8/26/24 of Past Non-Compliance (PNC) which occurred on 8/20/24. On 8/20/24 facility administration identified the resident was moved after a fall prior to being assessed by a licensed nurse and the delay in emergency services being notified to transfer the resident to the hospital. The facility completed the investigation, and the facility staff were in-serviced by 8/21/24. Review of the facility's policy, Response to Falls, dated October 24, 2022 showed: -Residents who have experienced a fall would have been promptly assessed and treated for injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils and to ensure the proper refrigeration, and/or disposal of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 76 residents with a licensed capacity for 78 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 5/17/23 between 8:56 A.M. [...]

Inspectors wrote2. Review of the facility's Tuberculosis Screening policy dated 10/24/22 showed: -Facility staff were screened for TB as part of the requisite employee health examination. -There were no specific instructions on the procedure of TB screening. Review of the facility's Administration and Interpretation of TB Skin Tests (TST) policy dated 10/24/22 showed: -Screening of facility staff for TB was done upon hire. -A licensed nurse or healthcare practitioner interpreted the TST 48 to 72 hours after administration. Review of the facility's undated Onboarding Standard Operating Procedure showed: -A TST must be read and documented within 48-72 hours from when it was administered. -No employee could start working prior to the reading of the first TST. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 3/4/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) for 10 out of 10 sampled new staff and to follow their policy to check the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for seven out of 10 sampled new staff. The facility census was 76 residents. Review of the facility's undated Onboarding Standard Operating Procedure showed: -Instructions to run all necessary background checks (Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees)) while a new hire was completing their onboarding. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure parameters were in place for the nursing staff to safely administer Metoprolol (a medication used to treat high blood pressure) and other blood pressure medications for three supplemental residents, (Resident #44, Resident #74, and Resident #10), and to ensure parameters were in place for the nursing staff to safely administer Digoxin (a medication used to treat heart failure and heart rhythm problems) for one supplemental resident (Resident #44) out of three supplemental residents for medication pass. The facility census was 76 residents. Review of the Mayo Clinic precautions for Digoxin (Oral Route Precautions), dated 5/1/23 showed: -Side effects include; dizziness, fainting, fast, pounding or irregular pulse, or slow heartbeat. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide restorative care (a program to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) following discharge from therapy services for one sampled resident (Resident #8) out of 18 sampled residents. This deficient practice had the potential to effect all residents who were discharged from therapy services to a restorative program. The facility census was 76 residents. Review of the facility's Restorative Nursing Program Guidelines policy, dated 10/24/2022, showed: -The program focused on achieving and maintaining physical, mental and psychosocial functioning. -A resident started the Restorative Nursing Program when a resident was discharged from formalized physical, occupational or speech rehabilitation therapy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were tested and/or screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five sampled residents (Residents #14, #21, #27, #55 and #56) out of five residents sampled and to wash or sanitize hands between glove changes during wound care for one sampled resident (Resident #50) out of 18 sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Nurse Aide (NA) Registry for two out of ten sampled employees to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 73 residents. 1. Record review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A, a housekeeping supervisor, was hired on 12/21/20. -Employee C, a dietary worker, was hired on 2/22/21. Record review of the above employees' employee files showed no check of the NA Registry to ensure they did not have a Federal Indicator prohibiting them to work in a certified facility. During an interview on 6/28/21 at 10:00 A.M., the Administrator said: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's medications were kept in a clean, sanitary, and secured medication cart or medication room, to ensure expired medications were destroyed/discarded, to ensure opened medications had the date they were opened written on the container, failed to ensure there was no food stored in with the medications, to ensure there were no cleaning supplies being stored/kept in the medication drawer, to ensure medications were removed from the medication cart when a resident discharged from the facility in two out of four medication carts, one treatment cart, and one medication room, and failed to ensure medications were labeled and matched the physician's order for one resident (Resident #500) out of 18 sampled residents. The facility census was 73 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the walk-in refrigerator floor clean; to retain a thermometer in the walk-in freezer to confirm correct temperatures; to safeguard plastic cutting boards were in good condition to avoid food safety hazards; to separate damaged food stuffs; and to ensure the proper refrigeration or disposal of food products. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 73 residents with a licensed capacity for 78. 1. Observations during the initial Kitchen inspection on 6/21/21 between 9:05 A.M. and 1:31 P.M. showed the following: -On a large can dispenser rack in the Dry Storage room there was a 6 pound (lb.) 6 ounce (oz.) can of white diced potatoes dented on the bottom rim and a 7 lb. 5 oz. can of baked beans dented on a lower back side. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress setting following manufacturer's guidelines and to ensure a Broda chair (a specialized tilt in space wheelchair used for comfort and positioning) was the appropriate size for one sampled resident (Resident #21) out of 18 sampled residents. The facility census was 73 residents. 1. Record review of Resident #21's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the wishes of a resident to be a Do Not Resuscitate (DNR a legal order indicating that a person does not want to receive cardiopulmonary resuscitation (CPR an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person) if that person's heart stops beating) for one sampled resident (Resident#44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Cardio-Pulmonary Resuscitation (CPR) dated [DATE] showed: -Residents may elect to execute an advanced directive to have CPR withheld in the event of a cardiac or respiratory arrest. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain one sampled resident's (Resident #219) dignity by allowing the bottom half of the resident to be exposed during cares and to attempt to provide privacy for one sampled resident (Resident #50) who had removed his/her shirt in the day area of the unit out of 18 sampled residents. The facility census was 73 residents. Note: A policy related to resident dignity was requested from the facility Director of Nursing (DON) on 6/28/21 and he/she reported that the facility had no such policy. 1. Record review of Resident #219's undated face sheet showed the resident had the following diagnoses: -Dementia without behaviors (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). [...]

Inspectors wroteBased on interview, and record review, the facility failed to adequately prepare one resident for a planned surgery by not ensuring the resident was kept Nothing by Mouth (NPO) which resulted in the surgery having to be rescheduled for one sampled resident (Resident #44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy, titled Physician Orders, dated 10/28/15 showed: -Physician orders were obtained and carried out in a systematic, organized fashion so resident care could be provided in a safe and consistent manner. -Once an order was received, it must be carried out as soon as possible. -Carrying out the order consisted of, but was not limited to, transcribing the order and notifying other applicable departments. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete weekly weights as ordered for one sampled resident (Resident #5) and to schedule a Computed Tomography scan (CT-provides detailed images of internal organs) as ordered for one sampled resident (Resident #6) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's physician orders policy dated 10/28/15 showed: -All general guidelines for obtaining physician orders applied to nutritional/dietary and diagnostic testing orders. -The nurse was responsible for contacting the provider who will be performing the diagnostic test to make an appointment. 1. Record review of Resident #6's care plan dated 12/31/20 showed the resident: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent three near falls for one sampled resident (Resident #50); and to ensure one sampled resident (Resident #319) received his/her morning medications out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's Accidents and Incidents policy dated 2/13/20 showed: -The facility should assess each resident's risk of an accident including the need for supervision. -Interventions should be implemented to prevent accidents including adequate supervision. 1. Record review of Resident #50's skin note dated 3/31/21 showed: -The resident rolled out of his/her bed and onto his/her fall mattress. -It was care planned that the resident would lie on the mattress on the floor at his/her will. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and care by not obtaining physician ordered laboratory tests for one sampled resident (Resident #44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Physician Orders, dated 10/28/15 showed: -Physician's orders were to be obtained and carried out in a systematic, organized fashion so that resident care could be provided in a safe and consistent manner. -Once obtained the order must be carried out as soon as possible. -In the event an order could not be implemented the nursing staff must notify the physician who wrote the order to discuss care alternatives. 1. Record review of Resident #44's face sheet showed the resident was admitted on [DATE] then readmitted on [DATE] with the following diagnoses: [...]