Four Seasons Rehabilitation & Care

In the surveyor’s words

From the most serious findings on record at Four Seasons Rehabilitation & Care, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF756May 15, 2025

  Based on record review and interview, the facility failed to ensure the physician responded to monthly medication regimen reviews (MMR) for 3 (#4, 5 and #21) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 42 residents who resided in the facility. Findings: A Medication Monitoring policy, dated 10/01/18, read in parts, For non-Urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident- but no later than their next routine visit to assess the resident- and the Attending Physician should document in the medical record .If the Attending Physician fails to address a recommendation or document a rationale for rejecting a recommendation: The DON, Medical… […]

• No harm, potential for more than minimal, patternF641Jan 29, 2024

  Based on record review and interview, the facility failed to ensure MDS assessment accurately reflected the residents' status related to a GDR which was clinically contraindicated for one (#16) of five residents whose medications were reviewed. The administrator identified 44 residents who resided in the facility. Findings: Res #16 had diagnoses which included schizoaffective disorder, major depressive disorder, and anxiety disorder. A MRR, dated 12/13/23, documented the resident received Risperdal 0.5 mg twice a day for schizoaffective disorder. The MRR documented a request for a GDR. The physician signed the MRR on 01/02/24 and documented the resident was stable at present and did not want a reduction. […]

• No harm, potential for more than minimal, patternF644Jan 29, 2024

  Based on record review and interview, the facility failed to ensure OHCA was contacted when residents had serious mental illnesses for two (#11 and #29) of two residents reviewed for PASRR assessments. The DON identified 44 residents resided in the facility. Findings: 1. Res #11 was admitted to the facility on [DATE] and had diagnoses which included major depressive disorder. A PASRR level I, dated 04/04/18 did document the resident had diagnosis of serious mental illness. On 08/13/21, the physician diagnosed the resident with schizoaffective disorder. On 01/25/24 at 10:29 a.m., the MDS coordinator stated that the OHCA was not notified of the new diagnosis of schizoaffective disorder. 2. […]

• No harm, potential for more than minimal, patternF657Jan 29, 2024

  Based on record review, and interview, the facility failed to update a comprehensive care plan for three (#8, 11, and #29) of three sampled residents reviewed for revision of care plans. The facility failed to update care plans related to: a. pressure ulcers for Res #8, b. bed rails and low air mattress for Res #11, and c. schizoaffective disorder for Res #29. The administrator identified 44 residents who resided at the facility. Findings 1. Resident #8 was admitted on [DATE] with diagnoses of multiple sclerosis, overactive bladder, chronic pain, chronic kidney disease, and diabetes mellitus type II. A revised care plan, dated 09/18/23, documented skin was intact and without evidence of redness, irritation, maceration, or open areas. […]

• No harm, potential for more than minimal, patternF677Jan 29, 2024

  Based on record review and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#16) of one sampled residents for assistance with bathing. The administrator identified 44 residents who resided in the facility. Findings: Res #16 had diagnoses which included myotonic muscular dystrophy, lack of coordination, muscle weakness, schizoaffective disorder, and major depressive disorder. A physician order, dated 03/25/22, documented nail care to be provided on bath days Monday, Wednesdays, and Fridays on the three to eleven shift. A care plan, last revised on 10/09/23, documented the resident required the assistance of one for bathing. […]