The Win Post-Acute

In the surveyor’s words

From the most serious findings on record at The Win Post-Acute, in the surveyor’s own words.

• Actual harm, isolatedF600May 30, 2024

  Based on interview and record review, one of two sampled residents (Resident 1) was not free from physical abuse when Resident 1 was found in bed with multiple bruises to the face and arms, swelling on the bridge of the nose and right eyebrow, a cut on the lower lip, blood in the mouth, on the lips, and on the fingers, and chipped teeth. Resident 1 passed away, and the immediate cause of death was documented as, Blunt force injury [injury caused by forceful impact from an object without sharp edges or points] of head complicating hypertensive [having high blood pressure] and atherosclerotic cardiovascular disease [heart disease involving plaque buildup in the arteries]. […]

• Actual harm, isolatedF607Jun 11, 2021

  Based on observation, interview, and record review, the facility failed to implement their written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) policy for one of 24 sampled residents (Resident 14) when certified nursing assistant A (CNA A) continued to provide direct care for activities of daily living (ADLs, such as bed mobility, transfer, dressing, toileting, bathing, personal hygiene, locomotion on unit, and locomotion off unit), had interactions with Resident 14 during weights monitoring and assistance with social dining after an abuse incident investigation when Resident 14 alleged CNA A committed verbal abuse. […]

• Actual harm, isolatedF760Mar 10, 2021

  Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was free from significant medication errors when a student nurse, without the supervision of the instructor, administered Resident 2's ten (10) medications to Resident 1. This failure resulted in Resident 1 experiencing lethargy (deep unresponsiveness), dizziness, and [MEDICAL CONDITION] (low blood pressure), had to be admitted to an acute care hospital with transfer to the intensive care unit (ICU), and a stay in the hospital for seven (7) days for [MEDICAL CONDITION] due to the accidental administration of three medications that used to treat high blood pressure: [MEDICATION NAME], and [MEDICATION NAME] while she had low blood pressure diagnosis. […]

• No harm, potential for more than minimal, patternF695May 9, 2025

  Based on observation, interview and record review the facility failed to follow professional standards of practice for oxygen administration for three of nine residents receiving oxygen therapy in the facility when: 1. Resident 20 was administered the wrong dose of oxygen. 2. Resident 49 was administered oxygen without a doctor's order. 3. Resident 16 was administered the wrong dose of oxygen. These failures had the potential to negatively affect Resident 20's, Resident 49's, and Resident 16's health. Findings: 1. During a concurrent observation and interview on 5/5/25, at 1:17 p.m., with Registered Nurse (RN) A, in Resident 20's room, Resident 20 was observed wearing a nasal cannula (plastic tubing which supplies oxygen from a machine). […]

• No harm, potential for more than minimal, patternF730May 9, 2025

  Based on interview and record review, the facility failed to ensure 40 out of 69 Certified Nursing Assistants (CNAs) who have worked at the facility for over one year were reviewed annually for a performance review per federal regulation. This failure resulted in the facility being unaware of 40 CNA's performance through the prior year. This failure also had the potential for CNA's performance to be below the standard or practice for patient care. Findings: During a review of CNA I's employee file, undated, employee file indicated, no annual performance review was documented. CNA I's hire date was 9/29/2021 During a review of CNA J's employee file, undated, employee file indicated, no annual performance review was documented. […]