Inspection·February 13, 2020

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the activity calendar, resident interview, and staff interview, the facility failed to ensure a resident was able to participate in activities of his/her choice. This affected one of one residents reviewed for choices (Resident #53) in a sample of 18. The facility census was 89. Findings include: Review of the medical record for Resident #53 revealed an admission date of 01/04/20. Review of the Minimum Data Set (MDS) Assessment completed 01/11/20 revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS indicated the resident was totally dependent upon two staff for transfers. The MDS further stated the resident had indicated it was very important to him/her to do things with groups of people and to do his/her favorite activities. A physician's order on 01/04/20 revealed the resident required a hoyer lift for transfers. Review of the plan of care revealed an intervention was added on 02/10/20 to modify the resident's daily schedule, treatment plan as needed to accommodate activity participation. Observations on 02/10/20 at 12:31 P.M., 12:58 P.M., 3:36 P.M., and 6:30 P.M. revealed Resident #53 to be in bed in her room. Interview with Resident #53 on 02/10/20 at 3:25 P.M. revealed she had told both aides on her hallway today that she wanted to get up before 1:30 P.M. so she could attend bingo. She stated staff did not get her up, so she was unable to attend bingo. She stated there was a manicure activity at 3:00 P.M. that she would also have attended if staff had gotten her up. Interview with Activity Director #43 on 02/11/20 at 3:00 P.M. revealed Resident #53 likes to attend bingo, [NAME], and groups that increase cognition. She stated she also likes book club on Monday nights. She stated Resident #53 did not attend bingo on 02/10/20 and she was surprised she was not there. She further confirmed the resident did not attend book club on 02/10/20 (Monday). Review of the activity calendar revealed on 02/10/20 bingo was scheduled at 1:30 P.M., manicures at 3:00 P.M. and book club at 6:30 P.M. Interview with Licensed Practical Nurse #3 on 02/12/20 at 10:00 A.M. revealed if Resident #53 wants to get up, the staff try their best and will try to find help to get her up as it takes four staff to get her up. She stated she did not know if the resident wanted up on 02/11/20. Interview with State Tested Nursing Assistant #66 on 02/12/20 at 9:56 A.M. confirmed she provided (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 365669 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)