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Deficiency Records for Four Seasons Living Center
A list of the most recent deficiencies for Four Seasons Living Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Four Seasons Living Center. 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 | 2024-04-23 | 2024-05-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-15 | 2024-04-26 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-07-28 | 2023-10-20 | N |
| Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. | Health | 2023-07-28 | 2023-10-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-09-18 | 2023-10-20 | Y |
| Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. | Health | 2023-09-18 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-28 | 2023-09-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-07-28 | 2023-09-11 | 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 | 2023-07-28 | 2023-09-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-28 | 2023-09-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-28 | 2023-09-11 | 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 | 2023-07-28 | 2023-09-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-07-28 | 2023-09-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-28 | 2023-09-11 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-28 | 2023-09-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-28 | 2023-09-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-28 | 2023-09-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-28 | 2023-09-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-28 | 2023-09-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Meet other general requirements. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-28 | 2023-09-11 | 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 | 2023-07-28 | 2023-09-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-16 | 2023-01-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-26 | 2022-12-10 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Meet other general requirements. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-24 | 2022-05-13 | 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 | 2022-03-24 | 2022-05-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-24 | 2022-05-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-24 | 2022-05-12 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-03-24 | 2022-05-12 | 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 | 2022-03-24 | 2022-05-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-24 | 2022-05-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-24 | 2022-05-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-24 | 2022-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-24 | 2022-05-12 | 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 | 2022-03-24 | 2022-05-12 | N |
| Post nurse staffing information every day. | Health | 2022-03-24 | 2022-05-12 | 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 | 2022-03-24 | 2022-05-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-24 | 2022-05-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-05-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-24 | 2022-05-10 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-24 | 2022-05-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-05-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-24 | 2022-05-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-24 | 2022-05-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-24 | 2022-05-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-13 | 2022-02-21 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-13 | 2022-02-21 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-28 | 2019-12-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-10-28 | 2019-12-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-28 | 2019-12-11 | 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 | 2019-10-28 | 2019-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-28 | 2019-12-11 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-28 | 2019-12-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-28 | 2019-12-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-28 | 2019-12-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-28 | 2019-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-28 | 2019-12-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-28 | 2019-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-28 | 2019-12-11 | N |
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