Four Seasons Living Center

In the surveyor’s words

From the most serious findings on record at Four Seasons Living Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 16, 2022

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate residents who tested positive for Covid-19 from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for seven resident (Resident #2, #4, #6, #8, #10, #12, #15, #17, and #18) at an increased risk of contracting Covid-19 due to prolonged exposure. […]

• Immediate jeopardy, isolatedF689Dec 8, 2025

  Based on observation, interview, and record review, facility staff failed to ensure the doors on the Tiger Medical Unit, a secured unit, were monitored during a fire alarm test which resulted in one resident (Resident #27) eloping from the facility at approximate 3:00 P.M. In addition, staff failed to complete hourly face checks for the resident, did not check on the resident after he/she missed dinner and smoke breaks, and did not notice the resident was missing until 9:00 P.M. Facility staff further failed to properly complete a thorough head count to ensure all residents were in the facility after the fire drill when staff were made aware two residents (Resident #116 and #112) had left the facility when the unit doors were left unattended and unlocked. […]

• Immediate jeopardy, isolatedF689Sep 23, 2021

  Based on observation, interview and record review, the facility failed to ensure the resident environment was free from accident hazards, for one resident (Resident #1) when staff allowed the resident to smoke a cigarette with his/her oxygen on. The facility census was 235. The administrator was notified on 9/15/2021 at 5:00 P.M. of an Immediate Jeopardy (IJ) which began on 9/15/21. The IJ was removed on 9/17/21 as confirmed by surveyor onsite verification. Review of the facility's Smoking Safety Regulations, last reviewed and approved on 7/9/2021, showed staff are educated as follows: -The facility will post No Smoking signs with the international symbol for no smoking for any room, ward or compartment where flammable liquids, combustible gases or oxygen is used or stored and in any… […]

• Immediate jeopardy, isolatedF600Jul 16, 2021

  Based on interview, and record review, facility staff failed to ensure four residents (Resident #1, #2, #3, and #4) remained free from abuse when Housekeeper A brought methamphetamines (an illegal synthetic stimulant drug) into the facility and sold the drug to four residents (Resident #1, #2, #3 and #4) for their use. The facility census was 231. On 07/16/21 at 12:10 P.M., the administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 06/10/21. On 06/10/21, the administrator identified the housekeeper brought methamphetamines into the facility to sell to the residents. Upon discovery, staff suspended the employee pending investigation, conducted an investigation, and notified appropriate parties. […]

• Actual harm, isolatedF760Jun 12, 2026

  Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when Registered Nurse (RN) A did not verify admission physician's orders, which resulted in staff not administering diabetic medications and resident hospitalization with Diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes that occurs when the body lacks enough insulin to use blood sugar). The facility census was 224.The administrator was notified on 06/12/26 of Past Non-Compliance which occurred on 06/08/26. […]