The Win Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services in accordance with professional standard of practice for one of two residents (Resident 1) when nursing staff failed to follow up an order for a medication. This failure had the potential for negative health outcomes related to not receiving prescribed medication as ordered.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1). This failure had the potential to delay abuse investigations and compromise Resident 1's safety. Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnosis of spinal stenosis (the space inside the bones of the spine gets too small), anxiety disorder (a mental health condition), difficulty in walking, and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/1/25, indicated his Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (BIMS score of 13-15 indicates cognitively intact). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for three of twelve residents (Residents 93, 3 and 87) did not reconcile when: 1. The medication was documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to Resident 93 but was not signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). 2. The medication was signed out of the CDR but not documented on the MAR for Resident 87 and Resident 3. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 35 sampled residents (Resident 34) was free from inappropriate and unnecessary medication use when the medication Midodrine HCI (to treat low blood pressure) was given outside of the ordered parameters. This failure had the potential for causing harm to Resident 34's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to identify the lack of annual performance reviews for Certified Nursing Assistants (CNAs) in their Quality Assurance Performance Improvement Plan (QAPI- a plan developed by the facility with the goal of improving conditions in the facility) when monitoring of employee files was not documented as reviewed for regulatory compliance, per the QAPI monitoring plan. As a result, the facility did not identify 40 of 69 CNAs employeed by the facility did not have a documented annual performance review. (see F730).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were implementing infection prevention practices when: 1. One of four Certified Nursing Assistances (CNA) failed to perform hand hygiene between residents during dining; 2. Resident 309's intravenous (IV, to deliver a medication into a vein) tubing tip left uncapped when not in use. During an observation on 05/06/25 at 12:53 p.m., Certified Nursing Assistant (CNA) F, was in the dining room sitting between Resident 5 and Resident 44 feeding them both lunch without cleaning her hands between Residents. During an interview on 05/06/25 at 3:07 p.m., CNA F stated, She washes hands prior to feeding the residents but does not clean hands between residents when feeding two residents at the same time. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for two of 15 residents (Resident 34 & 74) when there was no evidence the facility reviewed or revised the care plan with new recommendations to prevent the Resident from falling again. This failure had the potential to result in further falls and/or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to prevent and/or heal pressure ulcers (damage to the skin or underlying tissue as a result of prolonged pressure) for one of eight sampled residents (Resident 308) with pressureulcers when staff did not follow physician's order for heel protectors (device applied to the feet to minimize pressure on the heels). This failure had the potential to result in worsening of resdient 308's pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medication was removed in one of three medication carts (med cart AA)) when a bottle of Mirtazapine (used to treat depression [a mood disorder characterized by persistent sadness and a loss of interest in activities]) 15 milligrams (mg, unit of measurement) with expiration date of [DATE] was identified. The failure had the potential for residents to receive medications with reduced potency.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed. This failure had the potential for Residents in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314 to have less space available for daily care and assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for one of eight residents with the potential for skin problems when the facility failed to develop and implement Resident 49's care plan for preventative foot care. This failure had the potential for Resident 49's feet to deteriorate clinically.

Inspectors wroteBased 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].

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure 2 of 6 medication carts on 1 of 4 halls were not left unlocked and unattended.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed.

Inspectors wroteBased on interview and record review the facility failed to follow standards of care in obtaining and implementing physician's orders for the treatment and monitoring of skin tears (separation or tear in the skin commonly resulting from bumping or moving) for one of three sampled residents (Resident 1). Resident 1 sustained skin tears and physician's orders for treatment were not obtained and carried out. This failure resulted in the lacked of consistent monitoring of the wound status and had the potential for the skin tears to not optimally heal.

Inspectors wroteBased on interview and record review the facility failed to ensure medically-related social services was provided for one of three sampled residents who lost their dentures (Resident 1). There was no documentation of the dentures being lost, no social services documentation of a discussion with a family member regarding how to proceed to replace the loss and no policy addressing under what circumstance the facility was responsible. This failure placed the resident at risk for weight loss, oral discomfort, and general well-being.

Inspectors wroteBased 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. These failures resulted in Resident 14's emotional distress and social isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for five of 24 sampled residents (Residents 8, 64, 87, 99 and 309) and 2 non-sampled residents (Residents 108 and 84) when: 1. For Resident 64, dressing changes and flushes were not performed for a PICC line; 2. For Resident 8, facility staff administered oxygen without a physician's order; 3. For Resident 87, licensed nurses did not follow the physician order for oxygen administration; 4. For Resident 99 and Resident 308, fluid intake and output were not monitored; and 5. Medications were left on top of the medication cart unattended and the medication cart was unlocked. These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the ADDS (Automated Drug Delivery System) daily temperature and cycle count was monitored and recorded to ensure the accurate accountability of controlled substances (CS, medications having a high risk for abuse and addiction) for 1 of 3 residents (Resident 71, non-sampled). These failures could result in administering unsafe and ineffective medications to residents and the abuse of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 24 sampled residents (Residents 99, 310, and 44) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 99 there was no specific target behavior for the use of Wellbutrin (an anti-depressant medication); 2 Resident 310's remeron did not have appropriate indication and no specific target behavior for the use of fluoexitine (Prozac, an anti-depressant); 3. For Resident 44, there was no specific target behavior to monitor Seroquel (an antipsychotic medication to treat mental and mood conditions) and Depakote (a medication to treat seizures and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic high). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ staff with the appropriate competency and skills to carry out functions of the food and nutrition service when the dietary manager (DM) did not provide in-service to the kitchen staff regarding the proper procedures to sanitize food contact surface areas. This failure could affect proper washing and sanitation that could cause foodborne illness to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. wet pans were stored under the preparation table; 2. the coffee maker did not follow the daily cleaning per the manufacturer's guide; 3. there were undated open bag of macaroni and undated opened bag of pasta; 4. ice build-up in the freezer; 5. water leak on the dishwasher sink; 6. no air gap on the two compartment sink; 7. handwashing sink temp below 100 F 8. the top of the oven was sticky to the touch. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) to the residents who recieved food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 308's urinary bag was touching the floor; 2. Certified nursing assistant H (CNA H) and the licensed physician (LP) did not properly wear the N95 (a high filtering mask); 3. Staff did not know the procedure for point-of-care testing (POC, rapid test); 4. An isolation gown had a sticky material; 5. Certified nursing assistant Q (CAN Q) did not wear an isolation gown when transferring a resident in the yellow zone; 6. A resident was not wearing a facemask while being wheeled in the hallway and, 7. Resident 8 and Resident 109's oxygen cannulas were left hanging on the oxygen concentrator (device that concentrates the oxygen from a gas supply). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs were accommodated for six of 24 sampled residents (14, 31, 68, 28, 52, and 25) when the call light devices were not within reach. This failure had the potential for a delayed response and not meeting the resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comfortable and safe temperature levels for five of five rooms (Rooms A, B, C, D, E) when room air temperatures were not maintained in the range of 71 Fahrenheit (F, a scale of temperature) - 81 F. This failure had the potential to result in an unsafe environment for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services for one of 24 sampled residents (Resident 87) when restorative nursing aide (RNA, helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not followed after the rehab therapy evaluated Resident 87. This failure had the potential for Resident 87 to decline in activities of daily living (ADL's such as bed mobility, transfer, personal hygiene, toileting, and bathing) and prevent contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply food, fluids, and medications) placement was checked prior to administering medication for one of 28 opportunities (Resident 104). This failure had the potential to compromise the resident's care and could cause health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label medications and biologicals in accordance with the manufacturer's instructions and the facility's policy and procedure when: 1. One opened multi-dose vial (medication, usually in liquid, intended for more than one dose of medication) was found without an open date in the medication room; 2. One opened inhaler without an open date and one eye solution bottle were being used past the discard dates were found inside the medication cart in Station 4; and 3. One opened vial of insulin (medication to treat high blood sugar) with no open date and one eye solution bottle were being used past the discard dates were found inside the medication cart in Station 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the planned menu for renal diet and the cook did not communicate to the dietary manager (DM) regarding the change of the planned menu. This failure had the potential to result in the decreased nutrient intake intended to the residents on renal diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate food preferences for one of 24 sampled residents (Resident 36) when Resident 36 was served food to which he had allergies and disliked. This failure had the potential to affect his physical and medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose the garbage when the garbage bag was opened and the garbage container lid was not closed. This failure had the potential to attract pest and transfer harmful microorganism to food leading to foodborne illness to the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure multiple bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and service the residents receive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to store chemicals when a housekeeping cart was left opened in the resident hallway. This failure had the potential to compromise the health and safety of the residents.