Cycle 1
Health 2025-03-20 · Fire 2025-03-20
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Jackson, OH
Four Winds Nursing Facility
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
215 Seth Avenue, Jackson, OH
(740) 286-7551
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
United Church Homes
Operator or chain grouping
Approved since
1986-02-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,495
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.94
Baseline 21.49% · Performance 18.22% · Measure score 6.94 · Achievement 6.94 · Improvement 6.83
Healthcare-associated infections
0
Baseline 6.56% · Performance 7.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.53
Baseline 39.68% · Performance 49.25% · Measure score 3.53 · Achievement 3.53 · Improvement 0
Adjusted total nurse staffing
1.37
Baseline 3.32 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 0.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.07% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 14.56% · Lower 95% interval 8.19% |
| Discharge to community | 47.04% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 43.02% · Lower 95% interval 38.4% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.67% |
95.27%
3.4 pts better
|
Numerator 74 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 32.61% |
53.69%
21.1 pts worse
|
Numerator 15 · Denominator 46 |
| Discharge mobility score | 60.87% |
50.94%
9.9 pts better
|
Numerator 28 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 7.98% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 10.45% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 64.6% |
42%
22.6 pts better
|
Numerator 73 · Denominator 113 |
| Discharge function score | 58.7% |
56.45%
2.2 pts better
|
Numerator 27 · Denominator 46 |
| Transfer of health information to provider | 94.87% |
95.95%
1.1 pts worse
|
Numerator 37 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 6 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
92.4%
5.7 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.5% · Q3 98.4% · Q4 98.4% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
94.5%
2.8 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.5% · Q3 3.2% · Q4 3.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.0% |
26.1%
16.1 pts better
|
11.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.2% · Q3 15.8% · Q4 8.5% · 4Q avg 10.0% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.2%
1.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 8.5% · Q3 5.8% · Q4 3.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
25.4%
1.5 pts better
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 23.3% · Q3 26.4% · Q4 23.1% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
11.5%
1.8 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 11.1% · Q3 9.8% · Q4 7.3% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.6% |
7.7%
2.9 pts worse
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 12.6% · Q3 5.9% · Q4 12.4% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
6.2%
1.1 pts worse
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 12.3% · Q3 0.0% · Q4 9.6% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
21.7%
3 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 15.7% · Q3 27.4% · Q4 13.8% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
3.7%
0.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 1.5% · Q4 1.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
78.1%
7.7 pts better
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 84.9% · Q3 86.8% · Q4 90.4% · 4Q avg 85.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
12.5%
7.5 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 22.0% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
75.6%
12.4 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
25.1%
2.1 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 28.8% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-13 · Fire 2023-04-13
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-03-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-30
F · Potential for more than minimal harm
2023-04-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-04-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-15
F · Potential for more than minimal harm
2020-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-20
E · Potential for more than minimal harm
2020-02-13
K913 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
Corrected 2020-03-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-23
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-03-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
D · Potential for more than minimal harm
2023-04-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-15
D · Potential for more than minimal harm
2020-02-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-13
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-03-20
Penalties and ownership
What sits behind the stars
$0
2025-03-20
Payment Denial
Payment Denial · denial start 2025-06-20 · 10 days
10 day denial
Ownership
Brownfield, Thomas
Corporate Director · Individual
Casey, Mary
W-2 Managing Employee · Individual
Daniel, Kenneth
Operational/Managerial Control · Individual
Daniel, Kenneth
Corporate Officer · Individual
Green, Catherine
Corporate Director · Individual
Henry, James
Corporate Director · Individual
Kutschbach, Robert
Corporate Director · Individual
Renner, John
Operational/Managerial Control · Individual
Renner, John
Corporate Officer · Individual
Sheidler, Susan
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Jenkins Memorial Health Facility
Wellston, OH
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Edgewood Manor Of Wellston
Wellston, OH
4-star overall rating with 4-star inspections with $18,655 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Ayden Healthcare Of Jackson
Jackson, OH
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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