Inspection Reports for Four Winds Manor

The inspection was conducted to investigate complaints regarding failure to timely report suspected abuse or injuries of unknown origin and inadequate supervision to prevent accidents resulting in resident falls.

The facility failed to ensure timely reporting of an injury of unknown origin involving a resident's fracture and failed to implement fall prevention interventions for another resident, resulting in a fall with injury. Both incidents involved minimal harm and affected few residents.

The complaint investigation found that two CNAs observed a large bruise on a resident's left upper arm but did not report it, delaying notification until the next shift. Additionally, a resident with Parkinson's disease fell due to lack of fall interventions such as a floor mat and accessible call light, which were not in place at the time of the fall.

The inspection was conducted to assess compliance with regulatory requirements related to resident rights, staff background checks, resident assessments, treatment and care, medication administration, food safety, antibiotic stewardship, and immunization policies at Four Winds Manor nursing home.

The facility was found deficient in multiple areas including failure to honor residents' dignity and rights, incomplete staff background checks, inaccurate resident assessments, inadequate treatment and care for residents with change of condition, significant medication errors including crushing extended-release medications, serving food at unsafe temperatures, failure to follow antibiotic stewardship protocols, and incomplete documentation and offering of pneumococcal vaccinations.

The inspection was conducted following a complaint investigation regarding the inappropriate use of a physical restraint (a bed sheet) on resident R4 in her wheelchair during the night shift on 10/13-10/14/24.

The facility failed to ensure resident R4's rights to be free from physical restraints, as CNA1 used a bed sheet to secure R4 in her wheelchair without a physician's order or care plan authorization. The investigation concluded the use of the sheet was a restraint, CNA1 was suspended and later terminated, and education was provided. Additionally, the facility failed to provide documentation of a person-centered baseline care plan within 48 hours of admission for resident R8, and failed to follow proper hand hygiene infection control practices during catheter care for resident R9.

The complaint investigation was triggered by an allegation that CNA1 used a bed sheet as a restraint on resident R4 during the night shift of 10/13-10/14/24. The facility reported the incident to the state survey agency on 10/15/24 and submitted a follow-up report on 10/21/24. The investigation was inconclusive initially, but subsequent interviews and statements confirmed the use of the bed sheet as a restraint. CNA1 was suspended and later terminated. The complaint was substantiated.

The inspection was conducted due to a complaint investigation involving allegations of abuse, pressure ulcer care, diabetic foot care, nutrition, dialysis care, physician visits, food temperature, snack provision, food safety, and infection control at Four Winds Manor.

The facility failed to timely report an abuse allegation to the State Agency, did not provide adequate pressure ulcer care, failed to perform routine diabetic foot checks, did not maintain residents' nutritional status or notify physicians of weight loss, lacked comprehensive dialysis care plans and emergency procedures, missed required physician visits, served food at unsafe temperatures, did not offer snacks at bedtime despite long intervals between meals, improperly stored and handled food, and failed to ensure infection control practices including obtaining lab results for residents on antibiotics.

The complaint investigation included allegations of abuse involving resident R4, pressure ulcer care deficiencies for resident R14, lack of diabetic foot checks for residents R9, R14, R84, and R283, nutritional concerns for residents R25 and R29, inadequate dialysis care for resident R14, missed physician visits for residents R14 and R25, food temperature and snack provision issues affecting multiple residents, food safety violations, and infection control deficiencies involving residents R9, R24, R185, and R186.

The inspection was conducted in response to an allegation of neglect where a Certified Nursing Assistant (CNA C) reportedly did not toilet or change residents during her shift, resulting in residents on D-Wing being soaked.

The facility failed to thoroughly investigate the allegation by not obtaining statements from key staff (Med Tech D and CNA C), not interviewing residents, and not providing training to all staff to prevent recurrence. The allegation was found unverified by the facility, but surveyors found evidence that residents, including one cognitively intact resident (R4), were left wet for extended periods, causing distress.

The complaint involved an allegation that CNA C neglected residents by not toileting or changing them during her shift, resulting in soaked residents on D-Wing. The allegation was unverified by the facility's internal review, but surveyors found failures in investigation and training. Resident R4 reported being left wet for extended periods on multiple occasions, causing her to feel horrible.

The inspection was conducted following a complaint investigation related to accidents involving residents during transfers using mechanical lifts and slings.

The facility failed to ensure that two residents (R1 and R2) received care and services to prevent accidents during transfers. Specifically, staff did not follow care plans requiring two-person assistance, used incorrect sling sizes, and used incompatible slings with mechanical lifts, resulting in a resident fall causing a head laceration requiring staples. The facility lacked a formal process or policy for determining and documenting appropriate sling sizes and styles for residents.

The visit was complaint-related due to incidents where resident R1 fell from a mechanical lift due to improper sling use and lack of two-person assistance, resulting in a head laceration requiring staples. The facility investigation revealed staff used incorrect sling sizes and incompatible slings with lifts. Staff interviews indicated no formal policy or documentation for sling sizing and selection. Staff education and competency checks on lift and sling use were lacking.

The inspection was conducted due to allegations of abuse involving a resident (R1) who reported rough treatment by CNAs during care, prompting a complaint investigation.

The facility failed to immediately report the allegation of abuse, did not remove the implicated CNAs from resident care, and did not educate the CNAs on abuse reporting. The resident appeared upset and fearful due to the care received, and the facility did not take adequate steps to protect residents or ensure proper reporting.

The complaint involved allegations that CNAs were rough with resident R1 during care on multiple occasions, including forcing her hand on a walker despite her shoulder pain. The facility did not report the abuse allegation within the required 2-hour timeframe, did not remove the CNAs from resident care during the investigation, and did not educate the CNAs on abuse reporting. The resident was cognitively intact and expressed distress about the care received.

The inspection was conducted to evaluate the facility's compliance with care planning, provision of activities of daily living assistance, and maintenance of residents' range of motion and grooming needs.

The facility failed to develop complete care plans addressing the use of anticoagulant and antidepressant medications for certain residents, failed to provide necessary nail care for dependent residents, and failed to ensure appropriate use of a palm pillow to prevent contractures in a resident with limited range of motion.