Four Seasons Healthcare & Wellness Center, LP

In the surveyor’s words

From the most serious findings on record at Four Seasons Healthcare & Wellness Center, LP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 28, 2024

  Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) right to be free from sexual abuse (any sexual activity that occurs without consent [permission]), when on 11/23/2024 at approximately 8 p.m., Certified Nursing Assistant 1 (CNA 1) inserted his (CNA 1) fingers inside Resident 1's vagina (female genitalia [reproductive organ of a female involved in producing children]). CNA 1 then grabbed Resident 1's right hand and coerced (to persuade [cause] someone forcefully to do something that they are unwilling to do) Resident 1 to touch CNA 1's penis (male genitalia [reproductive organ of a male]). […]

• Immediate jeopardy, isolatedF600Oct 9, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) was free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) by: 1. […]

• Immediate jeopardy, isolatedF689Oct 9, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had a wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) received supervision to prevent elopement by: 1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. […]

• Actual harm, isolatedF692May 3, 2024

  Based on observation, interview, and record review, the facility failed to evaluate and modify the diet texture to meet the nutritional needs for one of one sampled resident (Resident 103). This deficient practice resulted in a 26.35 percent ([%] a part of every 100) or 39 pounds ([lbs.] unit of measurement) unplanned weight loss, within a six-month period for Resident 103. Findings: A review of Resident 1's Admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 ([DM] abnormal blood sugar), essential hypertension ([HTN] high blood pressure), anemia (a condition in which the body does not have enough healthy red blood cells), and hemiplegia (weakness of one side of the body that could affect the arms, legs and… […]

• No harm, potential for more than minimal, widespreadF814Jul 31, 2026

  Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when there were soiled gloves, tissue paper, empty plastic cup container on the floor and there was liquid coming out from one (1) of four (4) black dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) outside the facility. These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 185 of 185 residents living in the facility. […]