Four Winds Manor

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 3 sampled residents (R1). R1 voiced a concern regarding possible neglect, stating she did not receive care during the overnight shift. The facility staff failed to report the allegation to the Nursing Home Administrator and the facility failed to report the allegation to the state agency. Evidenced by:Facility policy, titled Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation, last reviewed 2/2026, includes: .All alleged incidents of mistreatment, neglect, exploitation or abuse of a resident. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are thoroughly investigated for 1 of 3 sampled residents (R1). R1 voiced a concern regarding possible neglect, stating she did not receive care during the overnight shift. The facility did not conduct a thorough investigation into the allegation. The facility did not put protections in place while completing their investigation. Evidenced by:Facility policy, titled Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation, last reviewed 2/2026, includes: .All alleged incidents of mistreatment, neglect, exploitation or abuse of a resident. The facility will thoroughly investigate, under the direction of the Administrator/designee. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that all alleged violations involving injuries of unknown source, are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 reportable incidents. On 10/27/25, 2 CNAs (Certified Nursing Assistants) observed a large bruise on R1's left upper arm. The 2 CNAs did not report the bruise. Upon further investigation, R1 had a non-displaced left humerus fracture. This is evidenced by:The facility's policy For Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation, dated 8/25, includes: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R2) reviewed for falls. R2's fall interventions were not in place when R2 had a fall resulting in a bloody nose. This is evidenced by:The facility's policy Comprehensive Care Planning, dated 4/23, includes: .will create an Initial Resident Baseline Care plan upon admission. Within 21 days and periodically a comprehensive, accurate, standardized assessment of each resident's function capacity is completed. The comprehensive assessment describes the resident's capability to perform daily life functions, strengths, and significant impairments in functional capacity. The results of the assessments . are used to develop, review, and revise the resident's comprehensive plan of care. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (R4) reviewed for change of condition. R4 had experienced a change in condition with an elevated blood pressure (BP) and severe headache. The facility failed to perform a thorough assessment and notify physician. R4 continued to show signs of a change in condition over the next two days with signs of restlessness and change in usual routine. R4 was sent to emergency room (ER) two days after onset of headache and elevated BP and was diagnosed with a left occipital lobe subacute infarct (stroke in the posterior (back) left part of the brain that occurred days or weeks ago, not acutely (within hours). This type of stroke primarily affects vision, leading to a loss of the right-side visual field in both eyes. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 1 of 3 supplemental residents (R29) and 22 residents eating in the main dining room out of a census of 31. R29 voiced concerns of cold food during screening. Surveyor conducted 1 test tray for the dining room which was not palatable. Evidenced by: Facility policy, entitled Standard Operating Procedures Serving Food dated 10/10/10 states, in part: .5. Hold potentially hazardous foods at the proper temperature. The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.16: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident is treated with dignity and respect in an environment that promotes maintenance or enhancement of his or her quality of life and recognizes each resident's individuality for 1 of 12 residents (R17) reviewed. R17 reported to Surveyor that they are continent of their bowels, but facility staff make them go to the bathroom in their depends. Evidenced by:The facility policy titled Rights of Residents, no date, states in part .As a basic premise, all residents have the right to a dignified existence, self- determination, and communication with and access to persons and services inside and outside of the facility. Quality of Life: This facility will care for each resident in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. Dignity: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all staff had background checks completed every four years which is part of preventing abuse. This affected 2 of 8 staff reviewed. Housekeeper C did not have a background check completed every four years. LPN D (Licensed Practical Nurse) did not have a background check completed every four years. Evidenced by:The facility's policy titled Policies and Procedures last reviewed on 8/2025 states in part .Components of Abuse Policy: 1. Screening: .B. Employment Background Checks are completed on all employees through [county's health and family services department] and Department of Justice at hire and every 4 years thereafter. On 9/3/25, Surveyor reviewed 8 random staff members to ensure compliance with background checks. [...]

Inspectors wroteBased on interview and record review, the facility must ensure the assessment accurately reflects the resident's status, this affected 1 of 16 sampled residents (R17). R17's comprehensive and quarterly Minimum Data Set (MDS) Assessments do not accurately reflect her bowel status. Evidenced by:The facility's policy titled MDS Completion last reviewed on 4/2024, states in part .Key Points: The RAI (Resident Assessment Instrument) is an interdisciplinary process in which input from the resident, family, care team staff as well as the medical record is used. It is intended that the assessment and interview process includes the resident's choices for care whenever possible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 (R34) of 1 out of 5 sampled residentsR34 has an order for metoprolol succinate (medication used to lower blood pressure) ER (extended release) 25 MG (milligrams) Tablet Extended Release 24 Hour dose to be administered once a day by mouth. This medication is labeled and ordered as an extended-release medication, meaning it is designed to release the active ingredients slowly over time, and are not to be crushed. Additionally, the order required staff to assess a pulse prior to administration. Surveyor observed MT G (Medication Technician) crush R34's Metoprolol extended release and administer it to R34 without assessing a pulse. Evidenced by:The facility policy entitled, Preparation and General Guidelines IIA2: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 3 supplemental residents (R19 &R10)) reviewed for antibiotic stewardship. R19 was treated for a urinary tract infection (UTI) with no documentation for criteria being met. R19 was treated with ciprofloxacin for UTI and culture and sensitivity (C&S) showed resistance to ciprofloxacin. R10 was treated with antibiotic for cystitis with no documentation for criteria being met and with no documentation of urinalysis (UA) and C&S.Evidenced by:The facility policy entitled Antibiotic Stewardship Program, dated 2/2024, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 2 of 5 residents (R6, & R7) reviewed for immunizations. [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure the rights of 1 of 1 resident's (R4) to be free from physical restraints imposed for the purposes of convenience.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide documentation of a person-centered baseline care plan within 48 hours of admission to ensure that 1 of 1 resident's (R8's) initial care needs would be provided.

Inspectors wroteBased on observation, interview and recird review the facility failed to follow appropriate infection control practices for hand hygiene before donning and after doffing gloves during indwelling urinary catheter care for 1 of 1 resident's (R9).

Inspectors wroteBased on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 33 residents (3 of 3 hallways and 2 of 2 test trays.) Residents voiced concerns at Resident Council regarding hot food being served cold. 2 of 2 test trays were observed to not be palatable. Residents (R) from all three hallways voiced concerns of food not being served at a desirable temperature (R283, R19, R14, and R3.) Evidenced by: The facility policy, titled Food Temperature Policy, revised 8/6/24, includes in part: It is the policy of (the facility) to provide safe and sanitary food items to the residents and to ensure that hazardous food items are cooked to correct temperatures . Any cold food items, ready to eat at or below 41 degrees F (Fahrenheit) . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there is more than 14 hours between the evening meal and breakfast. This has the potential to affect 33 of 33 residents and 3 of 3 units/hallways. R26, R185, R18, and R24 voiced concerns of snacks not being offered at bedtime. The facility is not offering all residents nourishing snacks at bedtime when their supper meal and breakfast meal are more than 14 hours apart. Evidenced by: The facility did not provide a policy related to meal frequency. Facility's posted meal times are as follows: Breakfast 8:00 AM . Lunch 12:00 PM . Supper 4:45 PM (It is important to note there are 15.25 hours between supper and breakfast.) On 7/31/24 at 1:00 PM during the Resident Council Task meeting, R26, R185, R18, and R24 voiced concerns of staff not offering snacks to them at bedtime. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 33 residents. Surveyor observed food that had been removed from original containers and not labeled with an open date. Surveyor observed opened food without open dates and expired food in circulation in the facility's kitchenette. Evidenced by: Facility policy, entitled Food Dating-Procurement, revised 8/6/24, includes: All items are dated upon delivery. Expiration dates are monitored . All food service staff need to label items with open and use by dates as needed. They all need to monitor for dates to make sure food is still fresh and safe to serve . Any items that are expired, past use by date, or appear questionable will be discarded . [...]

Inspectors wroteBased on interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 4 of 4 residents (R9, R14, R84, R283) reviewed for diabetic foot checks. R9 has no documentation of diabetic foot checks. R14 has no documentation of diabetic foot checks. R84 has no documentation of diabetic foot checks. R283 has no documentation of diabetic foot checks. This is evidenced by: The facilities Policy and Procedure entitled Diabetic Foot Checks/Screens dated 9/2023 documents the following in part: .Residents with diabetes will be assessed upon admission and quarterly or upon significant change in condition. Procedure: 1. The Wound Nurse or designee will assess any current diabetic resident for skin impairment upon admission . [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 sampled residents (R9) and 3 of 5 supplemental residents (R24, R185, R186). The facility's resident infection control line lists do not include lab reports, and culture and sensitivity (C&S) reports. The facility failed to ensure that the residents were on the correct antibiotics. This is evidenced by: The facility policy titled Infection Control Surveillance last reviewed on 2/2024 states in part, .9. Data to be used in the surveillance activities may include but are: .B. Lab reports .H. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 of 3 investigations reviewed for abuse involving (R4). R4 (Resident) reported an allegation of abuse to her daughter, who then reported it to the facility. The facility conducted a complete investigation but did not report the allegation to the State Agency (SA). This is evidenced by: The facility's policy titled Components of Abuse Policy last reviewed on 2/2024, states in part, .7. Reporting/ Response: A. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 of 1 resident (R14) reviewed. The facility failed to assess R14's wounds for 5 days after re-admission to the facility. The facility did not follow R14's wound care orders causing him to miss 13 dressing changes. Evidenced by: Facility policy, Physician Orders, undated, includes purpose- to accurately transcribe and carry out physician orders . Items to be included in orders: . Treatments . Facility policy, entitled Skin Integrity Management Program, updated 9/2023, includes: A licensed nurse within 24 hours of admission will complete a total body audit and evaluation, with documentation of findings . [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 of 2 resident (R25 and R29) reviewed for nutrition out of a sample of 16 residents. R25 experienced significant weight loss and the facility failed to promptly update the physician. The facility did not provide R25 with additional calories on admission when the initial dietary assessment identified weight loss as a concern and did not identify R25's food preferences in attempt to facilitate more oral intake. R29 experienced weight loss and the physician was not notified.

Inspectors wroteBased on interview and record review the facility did not develop a Comprehensive Care Plan or Policy and Procedures consistent with professional Standards of Practice for 1 of 1 resident's reviewed for dialysis care (R14) out of a total sample of 16. R14 receives renal dialysis three days per week. The facility's policy and procedure of dialysis care did not contain procedures for emergency situations related to hemodialysis access site, R14's care plan did not reflect the necessary care and treatment approaches for a resident receiving dialysis, including approaches for emergency situations related to hemodialysis access site, and staff were unsure of what to do if they found R14 bleeding out of his fistula. Evidenced by: Facility policy, entitled Hemodialysis Care, revised 3/2020, include: Implement emergent care as indicated due to change of condition . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 2 of 3 residents (R14 and R25) reviewed for physician visits out of a total sample of 16. R14 was not seen by a provider at least once every 30 days for the first 90 days after admission. R25 was not seen by a provider at least once every 30 days for the first 90 days after admission. This is evidenced by: Example 1 R14 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, type 2 diabetes, major depressive disorder, osteomyelitis (bone infection), and heart failure. R14 was seen by his physician on 6/11/24. There is no evidence of R14 being seen by a physician in July, therefore missing a 60-day visit after admission. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations, were thoroughly investigated, and that steps were taken to prevent further potential abuse for 1 of 4 residents (R4) reviewed for abuse. Med Tech D (Medication Technician/Certified Nursing Assistant) reported an allegation of neglect to the facility that CNA C (Certified Nursing Assistant) did not toilet/change residents during her shift and MED Tech D found all residents on the D-Wing to be soaked. The facility failed to obtain a statement from Med Tech D, failed to obtain a statement from CNA C, failed to interview any residents, and did not provide training to all staff to ensure this does not occur again. Evidenced by: The facility's, Components of Abuse Policy, reviewed 2/2024, states, in part as follows: [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to develop a care plan that addressed the use of anticoagulant medications and the use of antidepressant medications for 2 (Resident 18 and Resident 30) of 5 residents reviewed for unnecessary medications. The facility failed to develop a care plan for anticoagulant (medications used to thin the blood) use for Resident 18 and antidepressant use for Resident 30.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good grooming for 2 (Resident 17 and Resident 14) of 2 dependent residents sampled for activities of daily living care. Specifically, the facility failed to provide nail care for Resident 17 and Resident 14.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, it was determined the facility failed to ensure a resident with limited range of motion received appropriate services to prevent further decrease in range of motion for 1 (Resident 17) of 1 resident sampled with range of motion limitations.