Four Winds Manor
303 S Jefferson St, Verona, WI 53593 · Dane County · 44 certified beds · avg 35 residents/day · certified since Jul 1, 2000
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 4, 2025 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 29, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 22, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 27, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 4, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 4, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Aug 6, 2024 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 6, 2024 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Aug 6, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 6, 2024 | E · Potential for harm, repeated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Aug 6, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Apr 22, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 22, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 19, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 19, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 19, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 1 | G ▲ |
| 2024 | 11 | 0 | F |
| 2025 | 13 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
0 fines totaling $0, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Aug 22, 2023 | Payment Denial | 11 days from Sep 16, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.14 | 4.29 | 3.95 | top 18% in Wisconsin; top 11% in the U.S. |
| Registered Nurse hours | 1.31 | 1.01 | 0.69 | top 18% in Wisconsin; top 7% in the U.S. |
| Weekend total nurse staffing | 4.53 | 3.84 | 3.50 | top 21% in Wisconsin; top 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.96 | 0.68 | 0.48 | top 16% in Wisconsin; top 7% in the U.S. |
| Total nursing staff turnover (%) | 70.1 | 46.9 | 45.8 | bottom 7% in Wisconsin; bottom 6% in the U.S. |
| RN turnover (%) | 70.0 | 39.7 | 42.9 | bottom 8% in Wisconsin; bottom 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.84, RN 1.24, weekend 4.26. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Howard, Mary | Individual | 5% or Greater Direct Ownership Interest | 100% | 03/30/2014 |
| Howard, Mary | Individual | Corporate Officer | NOT APPLICABLE | 03/31/2014 |
| Howard, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/23/2003 |
| Howard, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 04/23/2003 |
| Kellogg, Shari | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/15/2025 |
| Kellogg, Shari | Individual | ADP of the SNF | NOT APPLICABLE | 09/15/2025 |
| Lubsen, Julia | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2019 |
| Lubsen, Julia | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2019 |
| Riedmaier, Rose | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/17/2025 |
| Riedmaier, Rose | Individual | ADP of the SNF | NOT APPLICABLE | 02/17/2025 |
| State Bank of Cross Plains | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 11/17/2015 |
| Wegner Cpas | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2014 |
| Wegner Cpas | Organization | ADP of the SNF | NOT APPLICABLE | 11/21/2025 |
| Wipfli LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2014 |
| Wipfli LLP | Organization | ADP of the SNF | NOT APPLICABLE | 11/21/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Badger Prairie HCC | 0.5 mi | Verona, WI | ★★★★★ | 5/5 | |
| Complete Care at Maple Grove LLC | 2.3 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Hebron Oaks | 3.5 mi | Madison, WI | ★★★★☆ | 3/5 | |
| Oak Park Place of Nakoma | 5.5 mi | Madison, WI | ★★★☆☆ | 3/5 | |
| Middleton Village Nursing and Rehab | 7.3 mi | Middleton, WI | ★☆☆☆☆ | 1/5 | |
| Capitol Lakes Health Center | 9.3 mi | Madison, WI | ★★★★☆ | 3/5 | |
| Ingleside Manor | 10.2 mi | Mount Horeb, WI | —/5 | SFF | |
| New Glarus Home | 12.9 mi | New Glarus, WI | ★★☆☆☆ | 2/5 | abuse |
| Madison Health and Rehabilitation Center | 13.3 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Waunakee Valley Senior Living | 14.1 mi | Waunakee, WI | ★★★☆☆ | 2/5 | |
| Oak Park Nursing and Rehab Center | 14.3 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Complete Care at Nazareth LLC | 15.9 mi | Stoughton, WI | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525656.