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Deficiency Records for Four Winds Manor
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.
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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-01 | 2024-10-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-01 | 2024-09-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-08-01 | 2024-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-01 | 2024-09-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-01 | 2024-09-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-06 | 2024-09-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-06 | 2024-08-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-06 | 2024-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-06 | 2024-08-23 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2024-08-01 | 2024-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-01 | 2024-08-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-01 | 2024-08-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-01 | 2024-08-23 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-08-01 | 2024-08-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-08-01 | 2024-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-06 | 2024-08-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-06 | 2024-08-13 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-08-06 | 2024-08-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-06 | 2024-08-06 | N |
| Provide appropriate foot care. | Health | 2024-08-06 | 2024-08-06 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-08-06 | 2024-08-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-01 | 2024-08-02 | N |
| Respond appropriately to all alleged violations. | Health | 2024-04-22 | 2024-05-17 | Y |
| 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 |
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