Winding Trails Post Acute

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Resident Rights Deficiencies

Assure the security of all personal funds of residents deposited with the facility.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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.

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Resident Rights Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain Fire/smoke doors in accordance with Life Safety Code NFPA 101 8.3.3.1 and 19.2.2.2.10.2. This was evidenced by the following:1. The facility failed to provide an annual fire door inspection report at the time of the survey.2. The fire d.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. This was evidenced by the following:1. Semi-annual kitchen hood semi-annual cleaning reports were not provided at the time of the survey. NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and liste.. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. This was evidenced by the following:1. A current annual fire extinguisher inspection report was not provided.Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another secti.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25, NFPA 13, and NFPA 101. This was evidenced by the following:1. A current 5-year fire sprinkler internal obstruction testing report was not provided.2. K.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. This was evidenced by the following:1. Fire drills were not conducted at varied times. The 1st shift fire drills for the third and fourth quarter were both conducted at 8:30am.NFPA 101, 19.7.1.6 Drills shal.. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a)The facility is a one (1) story, Type V (111) construction with a partial basement that is used for support services only, th.. The following observations were discussed and corrected during site visit:1. K920 - A small refrigerator in the office are was plugged into a power strip. This was corrected during the survey.2. K331 - Ceiling tiles are warped/not entirely flush in certain areas throughout the facility. Through observation during the survey, it was determined that the facility failed to meet the Combustible Decorations requirements in accordance with NFPA 101, 19.7.5.6. This was evidenced by the follwoing:1. Christmas decorations (Christmas trees) do not have evidence of being fire-rated.NFPA 101, 19.7.5.6 Combustible decorations shall be prohi.. Through observation during the survey, it was determined that the facility failed to meet the Electrical Systems - Receptacles requirements in accordance with NFPA 101, 19.5 and NFPA 70. This was evidenced by the following:1. Room 403 has exposed electrical.Life Safety Code Section 9.1.2 Electrical Systems. Electrical wiring and equipment s.. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101. This was evidenced by the following:1. The exit sign in the courtyard has a corner that has detached and is curling. The exit sign needs to be replaced due to sun damage/fading.NFPA 101, 4.5...

A recertification survey with complaint #CO38065, #CO38095, #CO38108 and Incident #38306 was completed from 11/18/24 to11/21/24. Eight deficiencies were cited. An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. One deficiency was cited. Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for two (#4 and #60) of two out of 35 sample residents.Specifically, the facility failed to appropriately assess Resident #4 and Resident #60 for self-administration of medications.Findings include:I. .. Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include:I. Resident interviewsResident #13 was interviewed on 11/18/24 at 1:31 p.m. He said the food was served co.. Based on observations, record review and interviews, the facility failed to ensure one (#39) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion out of 35 sample residents.Specifically, the facility fail.. Based on observations, record review and interviews, the facility failed to ensure one (#278) of three residents reviewed for activities out of 35 sample residents received individualized activities in accordance with standards of care.Specifically, the facility failed to provide person centered comforting activities for Resident #278 who was at en.. Based on record review and interview, the facility failed to conduct two exercises annually (in the last 12-month cycle) to test the facility' s emergency preparedness (EP) plan and maintain documentation of the facility' s response to all drills, tabletop exercises, and emergency events, and then revise the facility' s emergency plan, as needed.Specifi.. Based on record review and interviews, the facility failed to ensure a surety bond or otherwise provide assurance satisfactory to the secretary to assure the security of all personal funds of residents deposited with the facility.Specifically the facility failed to ensure the surety bond had the correct amount to cover the entire balance f.. Based on record review and interviews, the facility failed to ensure the facility' s binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#60 and #63) of three residents out of 35 sample residents. Specifically, the facility failed to:-Thoroughly explai.. Based on record review and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#63) of three residents out of 35 sample residents. Specifically, the facility failed to:-.. Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to provide a response, action and rationale for food concerns brought up in the resident council meetings. Findings include: I. Facility policy and procedure The grievanc..

A survey prompted by #CO37228, #CO37877, and #CO37900 was conducted on 10/14/24 to 10/15/24. One deficiency was cited. Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents out of three sample residents reviewed for discharge planning.Specifically, the facility failed to:-Provide an appropriate discharge process for Resident #3; and,-Notify the family that Resident #3 was transferred to another skilled nursing facility until after the resident had already been transferred.Findings include:I. Facility policy and procedureThe Discharge Summary and Plan policy, revised October 2022, was provided via email by the director of nursing (DON) on 10/14/24 at 11:33 a.m. It read in pertinent part,"When a resident' s discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge."Policy Interpretation and Implementation"The discharge summary includes a recapitulation of the resident' s stay at the facility and a final summary of the resident' s status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident."Discharge potential (the expectation of discharging the resident from the facility within the next three months."Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes:-Where the individual plans to reside;-Arrangements that have been made for follow-up care and services;-A description of the resident' s stated discharge goals;-The degree of caregiver/support person availability, capacity and capability to perform required care; and,-How the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care."The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan."The resident or representative (sponsor) is asked to provide the facility wit..