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Deficiency Records for Winding Trails Post Acute
A list of the most recent deficiencies for Winding Trails Post Acute. 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 Winding Trails Post Acute. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-07 | 2024-06-29 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-03-07 | 2024-06-21 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-03-07 | 2024-05-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-07 | 2024-04-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-07 | 2024-04-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-07 | 2024-04-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-04-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-07 | 2024-04-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-07 | 2024-04-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-04-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-07 | 2024-04-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-07 | 2024-04-17 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-03-07 | 2024-04-17 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-07 | 2024-04-17 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-20 | 2023-12-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-20 | 2023-12-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2023-12-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-08-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-14 | 2023-08-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-15 | 2023-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-15 | 2023-07-18 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-06-15 | 2023-07-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-15 | 2023-07-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-15 | 2023-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-15 | 2023-07-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-15 | 2023-07-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-15 | 2023-07-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-15 | 2023-07-18 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-06-15 | 2023-07-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-15 | 2023-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-07-18 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-06-15 | 2023-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-23 | 2023-04-26 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-28 | 2022-09-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-19 | 2022-06-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-19 | 2022-06-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-19 | 2022-06-14 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-04-19 | 2022-06-14 | 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 | 2022-04-19 | 2022-06-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-19 | 2022-06-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-19 | 2022-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-19 | 2022-06-14 | N |
| Provide activities to meet all resident's needs. | Health | 2022-04-19 | 2022-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-19 | 2022-06-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-19 | 2022-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-19 | 2022-06-14 | 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 | 2022-04-19 | 2022-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-19 | 2022-06-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-19 | 2022-06-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-19 | 2022-06-14 | 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 | 2022-04-19 | 2022-06-14 | N |
| Provide or obtain dental services for each resident. | Health | 2022-04-19 | 2022-06-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-19 | 2022-06-14 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-04-19 | 2022-06-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-19 | 2022-06-14 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-04-19 | 2022-06-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-19 | 2022-06-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-19 | 2022-06-14 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-19 | 2022-06-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-19 | 2022-06-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-19 | 2022-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-19 | 2022-05-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-04 | 2022-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-04 | 2022-05-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-21 | 2022-01-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-01 | 2021-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-01 | 2021-04-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-01 | 2021-04-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-02-01 | 2021-04-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-02-01 | 2021-04-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-02-02 | 2021-03-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-02 | 2021-03-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-02-02 | 2021-03-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-02-01 | 2021-03-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-02-01 | 2021-03-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-02-01 | 2021-03-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-01 | 2021-03-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-02-01 | 2021-03-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-02-01 | 2021-03-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-02-01 | 2021-03-17 | N |
| Respond appropriately to all alleged violations. | Health | 2021-02-01 | 2021-03-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-02-01 | 2021-03-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-02-01 | 2021-03-17 | 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 | 2021-02-01 | 2021-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-01 | 2021-03-17 | N |
| Provide activities to meet all resident's needs. | Health | 2021-02-01 | 2021-03-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-01 | 2021-03-17 | 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 | 2021-02-01 | 2021-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-01 | 2021-03-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-02-01 | 2021-03-17 | 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 | 2021-02-01 | 2021-03-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-01 | 2021-03-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-01 | 2021-03-17 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2021-02-01 | 2021-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-01 | 2021-03-17 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-02-01 | 2021-03-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-02-01 | 2021-03-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-02-01 | 2021-03-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-02-02 | 2021-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-02 | 2021-02-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-02 | 2021-02-16 | N |
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