Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Winds Nursing Facility during CMS and state inspections, most recent first.
Failure to Report Allegations of Staff-to-Resident Abuse: Multiple residents and staff reported that an LPN was rude, mean, had a bad attitude, and refused care, and several residents would not allow the LPN in their rooms. HR confirmed the LPN was suspended due to resident complaints, and the DON confirmed a resident’s family member reported rude behavior. However, the facility did not submit a self-reported incident to the State Agency as required by policy.
Incomplete Investigation of Abuse Allegations: The facility did not thoroughly investigate complaints about an LPN’s rude and mean behavior toward residents. Interviews and record review showed that multiple residents, a family member, and staff reported concerns, but the investigation did not include all residents, the accused LPN, or all relevant staff witnesses as required by policy. Residents involved had varying cognitive status, including intact cognition and moderate impairment.
A resident with diabetes, hypertension, and hyperlipidemia experienced nausea and diarrhea, prompting a physician to order several lab tests. Although nursing staff received and acknowledged the orders, the labs were not completed as required, and the orders were later discontinued. The Administrator confirmed the omission, and no explanation was provided for why the labs were not drawn.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for four residents. A resident on hospice care was given Macrobid without UTI symptoms or urinalysis. Another resident received Doxycycline after a family outing, despite no UTI symptoms. A third resident was treated with two antibiotics without timely culture results. Lastly, a resident was prescribed Ciprofloxacin for a resistant organism. The facility's policies were not followed, as confirmed by staff interviews.
A facility failed to notify a resident or their representative when the resident's personal funds account balance reached $200 less than the Medicaid resource limit. The resident's account balance exceeded $1800 from June 2024 to March 2025, but notification was delayed until March 2025. The Corporate Administrator confirmed the notification should have been made earlier.
A facility failed to thoroughly investigate an emotional/verbal abuse allegation involving a resident with paranoid schizophrenia. The resident reported fear of a nursing assistant due to past incidents. Although the nursing assistant was suspended, the facility did not interview other staff who worked that day, contrary to their policy. The corporate administrator confirmed the lack of additional staff interviews.
The facility failed to provide bed-hold notifications for three residents transferred to the hospital. A resident with multiple diagnoses was transferred due to high blood pressure and fever, another due to low hemoglobin levels, and a third with pneumonia and Flu A. In each case, no bed-hold notice was issued, as confirmed by the Corporate Administrator.
The facility failed to update the PASARR for two residents when there were significant changes in their medical conditions and treatments. One resident was prescribed a new antidepressant for depression, and another was diagnosed with anxiety and prescribed an antianxiety medication. Despite these changes, the PASARRs were not updated to reflect the new diagnoses and treatments, as confirmed by the Regional Director.
A facility failed to document care conference meetings for a resident with multiple diagnoses, including dementia and depression. Despite the resident's need for assistance with daily activities and a history of falls, only one care conference was documented over the past year. Interviews revealed discrepancies in the scheduling and documentation of these meetings, contrary to the facility's policy requiring regular interdisciplinary team care planning.
A facility failed to provide a detailed breakdown of fluid allocation for a resident on a fluid restriction, affecting hydration management. The resident, with multiple diagnoses, was on a 3500 ml/day fluid restriction, but the facility did not document fluid distribution across departments. Observations showed the resident lacked a bedside water pitcher, and staff confirmed fluids were only documented during meals. The facility's policy required documentation of fluid allocation, which was not followed.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of a long-term antibiotic. The resident was prescribed cefdinir for prophylaxis without an appropriate diagnosis or documentation from a specialist. The facility's plan of care did not address the antibiotic use, and the facility's policy on Antibiotic Stewardship was not followed.
A registered nurse failed to change gloves after handling soiled wound packing during a dressing change for a resident with a stage 4 pressure ulcer, violating the facility's infection control policy. The resident had a complex medical history, including chronic diseases and required substantial assistance. This breach was confirmed by the nurse, indicating a lapse in infection prevention protocols.
Failure to Report Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to the State Agency after multiple residents and staff described concerns about an LPN’s behavior toward residents. The deficiency affected four residents reviewed for abuse. Resident #54 had diagnoses including acute embolism and thrombosis of the left lower extremity, muscular dystrophy, and intra-abdominal and pelvic swelling, and had a BIMS score of 13/15. Resident #62 had diagnoses including heart failure, cerebral vascular disease, and major depressive disorder, with a BIMS score of 8/15. Resident #136 had diagnoses including type 2 diabetes, supraventricular tachycardia, and a displaced fracture of the cervical neck of the right humerus, with a BIMS score of 15/15. Resident #146 had diagnoses including intracranial injury with loss of consciousness, type 2 diabetes, and dysphagia, with a BIMS score of 11/15. Interviews with an LPN and CNAs revealed that multiple residents had complained that the LPN was rude, mean, had a bad attitude, and refused to provide care. One LPN stated that several residents, including Residents #54, #62, and #136, refused to allow the LPN in their rooms because of her bad attitude, and that the LPN had recently been suspended over resident-related situations reported to HR. HR confirmed the LPN was suspended due to complaints from residents about attitude and rudeness. The DON also stated that Resident #62’s daughter reported the LPN was rude to her mother. Review of the facility’s investigation file showed no self-reported incident was submitted to the State Agency, despite the facility policy stating the Executive Director or Administrator will notify the appropriate state reporting agency.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to document a thorough investigation of allegations of abuse involving four residents. Record review, staff interviews, and the facility’s investigation file showed that complaints about an LPN’s rude, mean, and rough behavior toward residents were reported by residents, family, and staff, but the investigation did not include interviews with all residents involved, the accused employee, or other staff members who may have witnessed or had contact with the residents. The facility policy required interviews with the resident, the accused, and all witnesses, including residents, family members, and employees who worked closely with the accused or alleged victims. Resident #54 had diagnoses including acute embolism and thrombosis of the left lower extremity, muscular dystrophy, and intra-abdominal and pelvic swelling, with a BIMS score of 13 indicating cognitive intactness. Resident #62 had heart failure, cerebral vascular disease, and major depressive disorder, with a BIMS score of 8 indicating moderate cognitive impairment. Resident #136 had type 2 diabetes, supraventricular tachycardia, and a displaced fracture of the cervical neck of the right humerus, with a BIMS score of 15 indicating cognitive intactness. Resident #146 had intracranial injury with loss of consciousness, type 2 diabetes, and dysphagia, with a BIMS score of 11 indicating moderate cognitive impairment. Interviews revealed multiple complaints about the LPN’s attitude and refusal to provide care, and the DON confirmed that the investigation did not include all residents and all staff.
Failure to Complete Ordered Laboratory Tests for Resident with Change in Condition
Penalty
Summary
The facility failed to ensure that laboratory services were completed as ordered for a resident who experienced a change in condition. The resident, who had a history of type II diabetes, hypertension, and hyperlipidemia, was admitted to the facility and later reported symptoms of nausea and diarrhea. The attending physician ordered several laboratory tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), A1C, and hepatic panel, to be drawn. Nursing documentation confirmed that these orders were received and that the resident and family were informed. However, the laboratory tests were not completed as ordered, and the orders were subsequently discontinued. An interview with the Administrator confirmed that the laboratory orders were not carried out, and no additional information was provided regarding the reason for the omission. Policy review indicated that nursing staff are responsible for ensuring all needed labs are included on the draw sheet and logged appropriately. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for change in condition.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in the inappropriate administration of antibiotics to four residents. Resident #126, who was receiving hospice care for end-stage congestive heart failure, was prescribed Macrobid for a urinary tract infection (UTI) without documented symptoms or a urinalysis. The Director of Nursing confirmed that the UTI criteria were not met, and the antibiotic was ordered by hospice without proper documentation. Resident #65, with diagnoses including diabetes and congestive heart failure, was prescribed Doxycycline for a UTI after a leave of absence with family, despite lacking documented symptoms or a urinalysis. The Director of Nursing confirmed that the resident did not meet the criteria for a UTI and that the antibiotic was ordered by an external physician without proper documentation. Resident #27, diagnosed with dementia and diabetes, was treated with two different antibiotics, Keflex and Levaquin, without documented urinary symptoms or timely urine culture results. The Director of Nursing acknowledged the delay in obtaining culture results and the lack of documentation for the second antibiotic. Resident #45, with multiple chronic conditions, was prescribed Ciprofloxacin for a UTI, but the organism was resistant to the antibiotic. The facility's policies on infection surveillance and antibiotic stewardship were not followed, as confirmed by interviews with the Director of Nursing and Corporate Administrator.
Failure to Notify Resident of Fund Balance Near Medicaid Limit
Penalty
Summary
The facility failed to notify a resident or their responsible party when the balance in the resident's personal funds account reached $200 less than the Medicaid resource limit, which is $2000. This deficiency affected one resident whose funds were managed by the facility. The transaction history showed that the resident's account balance reached $1904.15 on June 18, 2024, and remained above $1800 through March 20, 2025, with a current balance of $2076.79. The resident was on Medicaid, and the facility did not notify the resident or their representative of the balance status until March 18, 2025, which was not timely. The Corporate Administrator confirmed the oversight and acknowledged that the notification should have occurred in June 2024.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of emotional/verbal abuse involving a resident. The incident was reported when a resident expressed fear of a nursing assistant due to a previous incident during a shower and another in the resident's room. The resident claimed the nursing assistant was dismissive of her weakness and made a derogatory comment, although the resident could not recall the exact words. The facility categorized this as an allegation of emotional/verbal abuse and suspended the nursing assistant during the investigation. Despite the suspension and initial steps taken, the facility's investigation was incomplete as it lacked interviews with other staff members who worked on the day of the alleged incident or who had interactions with the nursing assistant. The facility's policy requires interviewing all potential witnesses, including staff who were in close contact with the resident or the accused employee. The corporate administrator confirmed that these additional staff interviews were not conducted, which led to the deficiency in the investigation process.
Failure to Provide Bed-Hold Notifications for Resident Transfers
Penalty
Summary
The facility failed to provide bed-hold notifications to residents or their representatives when residents were transferred out of the facility, affecting three residents. Resident #24, who was cognitively intact, was transferred to the emergency room due to not feeling well, with symptoms including high blood pressure and fever. Despite the transfer, there was no evidence of a bed-hold notice being given. This was confirmed by the Corporate Administrator. Resident #50, who was moderately cognitively impaired and used a walker, was taken to the hospital by family due to low hemoglobin levels and returned after receiving a blood transfusion. Similarly, no bed-hold notice was provided for this transfer. Resident #71, with diagnoses including metabolic encephalopathy and dementia, was transferred to the hospital with pneumonia and Flu A, but again, no bed-hold notice was issued. The lack of bed-hold notifications for these transfers was verified by the Corporate Administrator.
Failure to Update PASARR for Residents with New Diagnoses and Medications
Penalty
Summary
The facility failed to complete updated Pre Admission Screening and Resident Review (PASARR) assessments for two residents when there were significant changes in their medical conditions and treatments. Resident #14, who was admitted with diagnoses including dementia, delusional disorder, unspecified psychosis, unspecified mood disorder, and depression, was prescribed a new antidepressant medication, Zoloft, for depression. Despite this change, the facility did not update the PASARR to reflect the additional diagnosis of unspecified psychosis and the new medication for depression. This oversight was confirmed during an interview with the Regional Director. Similarly, Resident #23, who was admitted with diagnoses including dementia, unspecified psychosis, anxiety, depression, and paranoid personality disorder, was prescribed buspirone hydrochloride for anxiety. However, the facility did not update the PASARR to include the new diagnosis of anxiety. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment and behaviors such as wandering and physical symptoms directed towards others, requiring moderate assistance from staff. The failure to update the PASARR for Resident #23 was also confirmed during an interview with the Regional Director.
Failure to Document Care Conferences for Resident
Penalty
Summary
The facility failed to provide evidence of care conference meetings with a resident and/or the resident's representative, which is a requirement for developing a comprehensive care plan. The resident in question was admitted with multiple diagnoses, including dementia and depression, and was cognitively intact with no behaviors. The resident required assistance with activities of daily living and had experienced two or more falls without injury since admission. Despite these needs, the facility only documented one care conference meeting in the resident's progress notes over the past year. Interviews conducted with the resident and the social services staff revealed discrepancies in the documentation and scheduling of care conferences. The resident was unsure if any meetings had occurred to discuss her medical care and discharge plans. The social services staff confirmed that while a care conference was documented in the progress notes on one occasion, there was no other documentation of such meetings throughout the year. This lack of documentation and apparent failure to hold regular care conferences is contrary to the facility's policy, which requires the interdisciplinary team to develop and implement a care plan with the participation of the resident and/or their representative.
Failure to Document Fluid Restriction Breakdown for Resident
Penalty
Summary
The facility failed to ensure that a resident on a fluid restriction had a detailed breakdown of fluid allocation for each department, affecting the resident's hydration management. Resident #26, who was admitted with multiple diagnoses including dementia, depression, and chronic pain syndrome, was on a fluid restriction of 3500 ml per day due to excessive fluid intake. However, the facility did not provide a breakdown of fluid distribution across departments, as evidenced by the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) over several months. The plan of care and nutritional review recommended a fluid breakdown per meal/medication pass, but this was not implemented. Observations during the survey revealed that the resident did not have a water pitcher at the bedside, and interviews with staff confirmed that the resident had to request fluids. The Certified Nursing Assistants (CNAs) documented fluid intake only during meals, and the Registered Nurse (RN) confirmed that there was no documentation of fluid intake during medication administration. The facility's policy on fluid restriction required that the nursing and dining services departments determine and document the fluid allocation, which was not adhered to, leading to the deficiency.
Failure to Ensure Appropriate Diagnosis for Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of a long-term antibiotic. Resident #14, who was cognitively intact and required assistance with activities of daily living, was prescribed cefdinir, an antibiotic, for prophylaxis without an appropriate diagnosis. The resident's medical record did not contain any documentation from a urologist or specialist to support the long-term use of the antibiotic, and there were no indications of urinary tract infections in the past year according to nursing progress notes. The facility's plan of care did not address the antibiotic medication or its long-term use. The facility's policy on Antibiotic Stewardship required specific prescribing orders, progress notes explaining the reason for the antibiotic, and re-evaluation to ensure proper spectrum coverage. However, these requirements were not met in the case of Resident #14. The Director of Nursing confirmed that the resident was on an antibiotic with no diagnosis other than prophylaxis and that there was no documentation from a urologist. Additionally, the monthly medication pharmacy review did not provide any recommendations related to the use of the antibiotic for this resident.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during a wound care procedure for a resident with multiple complex medical conditions, including a stage 4 pressure ulcer. During the dressing change, the registered nurse did not change gloves after handling soiled wound packing, which is a critical step in preventing the transmission of infections. The nurse removed the soiled iodoform packing from the resident's wound and continued to clean the wound and handle new dressing materials without changing gloves, thereby compromising the sterility of the procedure. The resident involved had a significant medical history, including chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic kidney disease, among other conditions. The resident was cognitively intact and required substantial assistance for mobility. The facility's policy clearly stated the need to change gloves after removing old dressings and before applying new ones, which was not followed in this instance. This oversight was confirmed by the nurse involved during an interview, highlighting a lapse in following established infection control protocols.
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What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jenkins Care Community | 2.5 mi | ★★★★★ | 1 | 0 |
| Edgewood Manor Of Wellston | 4.3 mi | ★★★★★ | 7 | 0 |
| Ayden Healthcare Of Jackson | 8.2 mi | ★★★★★ | 0 | 0 |
| Maple Hills Skilled Nursing & Rehabilitation | 15 mi | ★★★★★ | 2 | 0 |
| National Church Residences Bristol Village | 21.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.