Safety Report: Winding Trails Post Acute
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
5Immediate jeopardy citations (severity J–L)
7Actual harm citations (severity G–I)
17Requirements cited on more than one inspection
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
L
Government finding: Ensure staff are vaccinated for COVID-19
Infection Control Deficiencies · Tag F888
L
Government finding: Perform COVID19 testing on residents and staff.
Infection Control Deficiencies · Tag F886
L
Government finding: Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F880
J
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Tag F867
G
Government finding: Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Nursing and Physician Services Deficiencies · Tag F841
G
Government finding: 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.
Administration Deficiencies · Tag F837
G
Government finding: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Tag F835
G
Government finding: Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F603
Citations by topic
6Abuse, neglect & exploitation
5Infection control
4Medications & pharmacy
4Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (10) than in the cycle before (15).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 4 | March 7, 2024; November 20, 2023; June 15, 2023; April 19, 2022 |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F867) | 3 | March 7, 2024; June 15, 2023; April 19, 2022 |
| Provide and implement an infection prevention and control program. (F880) | 3 | November 20, 2023; June 15, 2023; April 19, 2022 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 3 | November 20, 2023; June 15, 2023; April 19, 2022 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | October 2, 2025; April 19, 2022 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 2 | October 2, 2025; March 7, 2024 |
| 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. (F688) | 2 | November 21, 2024; April 19, 2022 |
| Provide activities to meet all resident's needs. (F679) | 2 | November 21, 2024; April 19, 2022 |
| Provide safe, appropriate pain management for a resident who requires such services. (F697) | 2 | March 7, 2024; June 15, 2023 |
| 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. (F838) | 2 | March 7, 2024; April 19, 2022 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. (F835) | 2 | March 7, 2024; April 19, 2022 |
| 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. (F578) | 2 | March 7, 2024; April 19, 2022 |
| 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. (F585) | 2 | November 20, 2023; April 19, 2022 |
| 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. (F758) | 2 | June 15, 2023; April 19, 2022 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 2 | June 15, 2023; April 19, 2022 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 2 | June 15, 2023; April 19, 2022 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | June 15, 2023; April 19, 2022 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| March 7, 2024 | Payment Denial | Payment denial for 85 days, starting April 5, 2024 |
| March 7, 2024 | Fine | $90,659 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
October 2, 2025 — 2 citations · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected December 9, 2025
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected December 9, 2025
November 21, 2024 — 8 citations
F
Assure the security of all personal funds of residents deposited with the facility.
No actual harm, but potential for more than minimal harm · Widespread · Resident Rights Deficiencies · F570 · corrected December 12, 2024
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · complaint · corrected December 20, 2024
E
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F565 · complaint · corrected December 20, 2024
D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F847 · corrected December 20, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected December 20, 2024
D
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected December 20, 2024
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · corrected December 13, 2024
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · corrected December 20, 2024
October 15, 2024 — 1 citation · complaint investigation
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · complaint · corrected November 1, 2024
March 7, 2024 — 14 citations (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected April 17, 2024
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected April 17, 2024
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 29, 2024
F
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F940 · complaint · corrected April 17, 2024
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · complaint · corrected April 17, 2024
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · complaint · corrected May 9, 2024
F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F835 · complaint · corrected April 17, 2024
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected April 17, 2024
E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F947 · complaint · corrected April 17, 2024
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected April 17, 2024
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected April 17, 2024
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 17, 2024
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected April 17, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · complaint · corrected June 21, 2024
November 20, 2023 — 4 citations · complaint investigation
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · complaint · corrected December 18, 2023
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected December 18, 2023
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected December 18, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · complaint · corrected December 18, 2023
June 15, 2023 — 14 citations
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected July 18, 2023
E
Have enough outside ventilation via a window or mechanical ventilation, or both.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F923 · corrected July 18, 2023
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected July 18, 2023
E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F813 · corrected July 18, 2023
E
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F697 · corrected July 18, 2023
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected August 18, 2023
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · corrected July 18, 2023
E
The resident has the right to receive notices in a format and a language he or she understands.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F574 · corrected July 18, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · corrected August 8, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected July 18, 2023
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected July 18, 2023
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected July 18, 2023
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected July 18, 2023
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected July 18, 2023
April 19, 2022 — 26 citations (includes serious)
L
Ensure staff are vaccinated for COVID-19
Immediate jeopardy to resident health or safety · Widespread · Infection Control Deficiencies · F888 · corrected June 14, 2022
L
Perform COVID19 testing on residents and staff.
Immediate jeopardy to resident health or safety · Widespread · Infection Control Deficiencies · F886 · corrected June 14, 2022
L
Provide and implement an infection prevention and control program.
Immediate jeopardy to resident health or safety · Widespread · Infection Control Deficiencies · F880 · corrected May 18, 2022
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F686 · corrected June 14, 2022
G
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Actual harm to a resident (not immediate jeopardy) · Isolated · Administration Deficiencies · F867 · corrected June 14, 2022
G
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Actual harm to a resident (not immediate jeopardy) · Isolated · Nursing and Physician Services Deficiencies · F841 · corrected June 14, 2022
G
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.
Actual harm to a resident (not immediate jeopardy) · Isolated · Administration Deficiencies · F837 · corrected June 14, 2022
G
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Actual harm to a resident (not immediate jeopardy) · Isolated · Administration Deficiencies · F835 · corrected June 14, 2022
G
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F603 · corrected June 14, 2022
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · corrected June 14, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected June 14, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F758 · corrected June 14, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected June 14, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F688 · corrected June 14, 2022
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected June 14, 2022
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected June 14, 2022
E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected June 14, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F585 · corrected June 14, 2022
D
Provide or obtain dental services for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F791 · corrected June 14, 2022
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected June 14, 2022
D
Assist a resident in gaining access to vision and hearing services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F685 · corrected June 14, 2022
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected June 14, 2022
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected June 14, 2022
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected June 14, 2022
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected June 14, 2022
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected June 14, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare