Inspection Reports for Four Seasons Retirement Center
1901 TAYLOR RD, IN, 47203
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 22, 2024, found Four Seasons Retirement Center in compliance following a paper review related to a residential complaint investigation. Earlier inspections showed a mix of compliance and deficiencies, including medication errors, timely physician documentation, and life safety code issues such as fire alarm and sprinkler system maintenance. Inspectors cited medication administration errors that led to an emergency room visit and noted deficiencies in emergency preparedness and fire safety in prior reports. Complaint investigations were mostly unsubstantiated except for one medication-related citation in October 2024. The facility’s record shows some improvement in life safety compliance over time, but medication management and timely clinical documentation remain areas with recurring issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
69% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 22, 2024
Visit Reason
Paper compliance review to the Investigation of Residential Complaint IN00441926 completed on October 8, 2024.
Findings
Four Seasons Retirement Center was found to be in compliance with 410 IAC 16.2-5 regarding the paper compliance review to the Residential Complaint Investigation.
Complaint Details
Investigation of Residential Complaint IN00441926; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 174
Deficiencies: 1
Oct 7, 2024
Visit Reason
The visit was conducted for the investigation of Nursing Home Complaint IN00444351 and Residential Complaint IN00441926.
Findings
No deficiencies were cited related to Nursing Home Complaint IN00444351. A state deficiency was cited related to Residential Complaint IN00441926 for failure to ensure a resident was free from receiving the wrong medication.
Complaint Details
Investigation of Nursing Home Complaint IN00444351 found no deficiencies related to the allegations. Investigation of Residential Complaint IN00441926 resulted in a state deficiency citation at R0297 for pharmaceutical services noncompliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a resident was free from receiving the wrong medication for 1 of 3 residents reviewed (Resident E). Resident E was administered another resident's medication (Zolpidem Tartrate 5mg) instead of prescribed Oxycodone HCL 10 mg, resulting in an emergency room visit. |
Report Facts
Census Bed Type - SNF: 15
Census Bed Type - Residential: 120
Census Bed Type - NCC: 39
Total Capacity: 174
Census Payor Type - Medicare: 14
Census Payor Type - Other: 40
Total Census Payor: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Stenner | Executive Director | Signed the report |
| Staff Member #2 | Qualified Medical Aide (QMA) | Named in medication error finding for administering wrong medication to Resident E |
| Director of Nursing | Director of Nursing (DON) | Notified about medication error incident |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 0
Jun 21, 2024
Visit Reason
This visit was conducted for the Investigation of Complaints IN00434634 at Four Seasons Retirement Center.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00434634 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 15
Census Bed Type - NCC: 36
Census Bed Type - Residential: 117
Census Bed Type - Total: 168
Census Payor Type - Medicare: 15
Census Payor Type - Other: 36
Census Payor Type - Total: 51
Inspection Report
Annual Inspection
Deficiencies: 0
May 29, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Four Seasons Retirement Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 13
Capacity: 30
Deficiencies: 8
Apr 23, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 04/23/2024 to assess compliance with Medicare and Medicaid participation requirements and life safety codes.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements, with multiple deficiencies noted including issues with smoke barrier door latching, fire alarm annunciator panel security, fire alarm system maintenance, sprinkler system installation and maintenance, building services inspection certificates, and fire drill documentation.
Severity Breakdown
SS=E: 1
SS=F: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 1 of 1 smoke barrier doors in the 300 hall. | SS=E |
| Failed to ensure 1 of 1 fire alarm annunciator panels was protected against unauthorized use. | SS=F |
| Failed to ensure 1 of 1 fire alarm systems was maintained in accordance with NFPA standards; noted deficiency regarding 12v7ah batteries. | SS=F |
| Failed to ensure spray pattern for sprinkler heads were not obstructed in 1 of 1 lobby storage closets. | SS=F |
| Failed to maintain ceiling construction near sprinkler heads in room 108 and rehabilitation closet. | SS=F |
| Failed to replace 7 sprinkler heads covered with rust/corrosion in various locations. | SS=F |
| Failed to ensure 1 of 4 fuel fired water heaters had current inspection certificates. | SS=F |
| Failed to conduct quarterly fire drills for 1 of 4 quarters on the second shift. | SS=F |
Report Facts
Certified beds: 30
Census: 13
Deficiencies cited: 8
Fire drill quarters missing documentation: 1
Sprinkler heads replaced: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Interviewed and involved in observations and corrective actions related to smoke barrier door, fire alarm system, sprinkler system, and water heater inspections | |
| Executive Director | Participated in exit conferences and review of findings |
Inspection Report
Life Safety
Deficiencies: 0
Apr 23, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 04/23/24 and completed on 05/16/24.
Findings
Four Seasons Retirement Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 167
Deficiencies: 2
Apr 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from April 1 to April 5, 2024.
Findings
The facility was found to have deficiencies related to timely physician visit notes for 4 of 14 residents and failure to obtain STAT labs timely for 1 of 2 residents reviewed. The facility submitted plans of correction and was found in compliance with State Residential Licensure requirements.
Severity Breakdown
SS=B: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure physicians' notes were provided in a timely manner for 4 of 14 residents reviewed for regulatory visits. | SS=B |
| Failed to obtain STAT (immediate) labs timely for 1 of 2 residents reviewed for laboratory services. | SS=D |
Report Facts
Census Bed Type Total: 167
Skilled Nursing Facility (SNF) beds: 14
Nursing Care Center (NCC) beds: 39
Residential beds: 114
Medicare census: 13
Other payor census: 40
Residents reviewed for physician notes: 14
Residents with delayed physician notes: 4
Residents reviewed for laboratory services: 2
Residents with delayed STAT labs: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Stenner | Executive Director | Signed the report and plan of correction |
Inspection Report
Re-Inspection
Census: 13
Capacity: 30
Deficiencies: 0
Apr 17, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 02/20/23.
Findings
At this PSR survey, Four Seasons Retirement Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare and Medicaid. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 30, 2023
Visit Reason
The inspection was a paper compliance review related to the Annual Recertification and State Licensure survey conducted on February 7, 2023.
Findings
Four Seasons Retirement Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 15
Capacity: 30
Deficiencies: 4
Feb 20, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.70(a) respectively.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to implement emergency power system inspection and testing, failure to ensure hazardous areas were properly enclosed with smoke resistant partitions, failure to provide combustion air from outside for fuel fired equipment, and failure to allow a 5-minute cool down period for the emergency generator after load testing.
Severity Breakdown
SS=F: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; monthly load testing documentation for the propane fired emergency generator was incomplete and cool down time was not recorded. | SS=F |
| Failed to ensure hazardous areas such as laundry room were separated from other spaces by smoke resistant partitions; openings above dryers exposed attic space. | SS=D |
| Failed to ensure laundry room with fuel fired dryers was provided with intake combustion air from outside; vent grill was covered. | SS=D |
| Failed to allow 5 minute cool down period after load test for emergency generator as required by NFPA 110. | SS=F |
Report Facts
Certified beds: 30
Census: 15
Emergency generator rating: 25
Months of generator testing reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Stenner | Executive Director | Named during exit conference and in report signature. |
| Director of Environmental Services | Interviewed and involved in observations and corrective actions; full name not provided. |
Inspection Report
Annual Inspection
Census: 119
Capacity: 164
Deficiencies: 5
Feb 7, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on February 1, 2, 3, 6, and 7, 2023.
Findings
The facility was found deficient in several areas including failure to ensure accident hazards were minimized during resident transfers, improper medication administration, failure to follow physician orders for laboratory and radiology services in a timely manner, and failure to follow manufacturer's guidelines for insulin pen administration.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to properly secure a resident's wheelchair during transfer resulting in a fall for 1 of 2 residents reviewed for accidents. | SS=D |
| Failed to administer medications appropriately for 1 of 9 residents reviewed for medication administration; a pill was left in the medication cup after administration. | SS=D |
| Failed to follow physician orders related to laboratory services for 1 of 9 residents reviewed; laboratory orders were not entered into the lab system resulting in missed lab draw. | SS=D |
| Failed to follow physician orders for a STAT chest X-ray in a timely manner for 2 of 9 residents reviewed; radiology vendor did not respond to STAT requests and documentation of physician notification was missing. | SS=D |
| Failed to follow manufacturer's guidelines for insulin administration for 1 of 5 residents observed during medication administration; insulin pens were not primed properly and pen tips were not cleaned with alcohol. | SS=D |
Report Facts
Survey dates: 5
Census Bed Type - SNF: 15
Census Bed Type - NCC: 30
Census Bed Type - Residential: 119
Total Capacity: 164
Census Payor Type - Medicare: 15
Census Payor Type - Other: 30
Medication count: 5
Insulin doses: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Stenner | Executive Director, HFA | Signed the report |
| LPN 2 | Licensed Practical Nurse | Named in insulin administration deficiency and re-education |
| RN 3 | Registered Nurse | Named in medication administration and laboratory/radiology deficiencies |
| BNA 4 | Basic Nurse Aide | Named in wheelchair transfer fall incident and re-education |
Inspection Report
Complaint Investigation
Census: 162
Deficiencies: 0
Dec 19, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00392024.
Findings
The complaint IN00392024 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00392024 was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - Residential: 123
Census Bed Type - Non-Certified Comprehensive: 29
Total Census: 162
Census Payor Type - Medicare: 10
Total Census Payor: 10
Loading inspection reports...
