Four Winds Manor

In the surveyor’s words

From the most serious findings on record at Four Winds Manor, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 4, 2025

  Based 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). […]

• Actual harm, isolatedF689Aug 22, 2023

  Based on observation, interview, and record review, the facility failed to ensure 2 of 3 (R1 and R2) residents reviewed for accidents received care and services to prevent accidents. On 8/3/23, CNA C (Certified Nursing Assistant) attempted to transfer R1 without a second person to assist as directed in R1's care plan. As R1 was transferring, the sling tilted sideways and R1 fell to the floor, causing R1 to receive a head laceration that required four staples. The facility completed a self-report and investigation; however, the facility failed to identify CNA C used an incorrect sling size. The facility does not have a process in place for identifying what size and style sling a resident should use. Surveyor observed R2 transferring with a lift and sling that were not compatible. […]

• No harm, potential for more than minimal, widespreadF804Aug 6, 2024

  Based 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… […]

• No harm, potential for more than minimal, widespreadF809Aug 6, 2024

  Based 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 . […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2024

  Based 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 [DATE], 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 . […]