Four Winds Nursing Facility

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF609May 18, 2026

  Based on record reviews, resident and staff interviews, review of facilities investigation report and facilities policy and procedure, the facility failed to report an allegations of staff to resident abuse to the State Agency. This affected four ( #54, #62, #136 and #146) of four residents reviewed for abuse. The facility census was 72. Findings include: 1. Review of records for Resident #54 revealed an admission date of 03/19/26 with diagnoses that included but are not limited to acute embolism and thrombosis of deep veins of left lower extremity, muscular dystrophy, and intra-abdominal and pelvic swelling.Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment completed on 05/01/26 for Resident #54 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15… […]

• No harm, potential for more than minimal, patternF610May 18, 2026

  Based on record reviews, resident and staff interviews, review of facilities investigation report and facilities policy and procedure, the facility failed to have documented evidence that an allegation of abuse was thoroughly investigated for residents. This affected four ( #54, #62, #136 and #146) of four residents reviewed for abuse. The facility census was 72. Findings include:1. Review of records for Resident #54 revealed an admission date of 03/19/26 with diagnoses that included but are not limited to acute embolism and thrombosis of deep veins of left lower extremity, muscular dystrophy, and intra-abdominal and pelvic swelling.Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment completed on 05/01/26 for Resident #54 revealed a Brief Interview for Mental Status… […]

• No harm, potential for more than minimal, patternF881Mar 20, 2025

  Based on medical record review, policy review, and staff interview, the facility failed to implement their antibiotic stewardship program that included antibiotic use protocols to ensure residents did not receive antibiotics when they were not warranted. This affected four (Residents #27, #45, #65, and #126) of six residents reviewed for antibiotic use. The facility census was 75. Findings include: 1. Review of the medical record for Resident #126 revealed an admitted [DATE]. The plan of care stated the resident was receiving hospice services for end stage congestive heart failure. Review of nurses notes revealed on 01/13/25 at 6:57 P.M. a new order was received for an antibiotic (Macrobid) due to a urinary tract infection (UTI). There were no symptoms of a UTI documented in the record. […]

• No harm, potential for more than minimal, isolatedF760Aug 6, 2026

  Based on resident record review and staff interview, the facility failed to ensure medication orders were obtained and appropriately discontinued in a timely manner. This affected one resident (#70) out of the three residents reviewed for medication administration. The facility census was 68.Findings Include:Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, pelvic and lumbar fractures, dysphagia, post-traumatic stress disorder, and subacute tardive dyskinesia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/30/26, revealed the resident was assessed to have severely impaired cognition.Review of Resident #70's medical record and hospital notes revealed she was hospitalized on [DATE]… […]

• No harm, potential for more than minimal, isolatedF773Jul 23, 2025

  Based on record review, review of physician notes, policy review, and interview, the facility failed to ensure laboratory services were completed as ordered. This affected one (#22) resident of three residents reviewed for change in condition. The facility census was 70. Findings include:Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including type II diabetes, hypertension, and hyperlipidemia. Review of a minimum data set (MDS) completed on 04/16/25 revealed Resident #22 had mildly impaired cognition and no behaviors. Review of a physician note dated 06/23/25 at 1:00 A.M. by Physician #125 revealed Resident #22 was seen due to reports of nausea with some meals and diarrhea. […]