A list of the most recent deficiencies for Four Winds Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-22 | 2023-09-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-20 | 2023-07-06 | Y |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-04-18 | 2023-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-19 | 2023-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-19 | 2023-05-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-19 | 2023-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-18 | 2023-05-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-18 | 2023-05-03 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-04-18 | 2023-04-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-04-18 | 2023-04-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-04-18 | 2023-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-09 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-03 | 2022-04-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-03 | 2022-04-01 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-03-03 | 2022-04-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-03-03 | 2022-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-03 | 2022-04-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-03 | 2022-04-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-03 | 2022-04-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-03 | 2022-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-03 | 2022-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-03 | 2022-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-03 | 2022-04-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-03-03 | 2022-04-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-03-04 | 2020-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-04 | 2020-04-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-03-04 | 2020-04-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-04 | 2020-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-04 | 2020-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-04 | 2020-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-02 | 2020-04-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-02 | 2020-04-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-02 | 2020-04-03 | N |
