ElderGrade

Inspection citations at The Win Post-Acute

35 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 0
2025 12 0
2024 3 1
2023 2 0
2021 17 1
D March 24, 2026 Tag F0658 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D July 28, 2025 Tag F0609 Complaint investigation Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0656 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

B May 9, 2025 Tag F0912 Corrected Jun 2025

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

No actual harm, minimal potential

D May 9, 2025 Tag F0761 Corrected Jun 2025

Pharmacy Service Deficiencies

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, potential for more than minimal harm

D May 9, 2025 Tag F0686 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0657 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

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, potential for more than minimal harm

E May 9, 2025 Tag F0880 Corrected Jun 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E May 9, 2025 Tag F0867 Corrected Jun 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

E May 9, 2025 Tag F0757 Corrected Jun 2025

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

E May 9, 2025 Tag F0755 Corrected Jun 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

E May 9, 2025 Tag F0730 Corrected Jun 2025

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

No actual harm, potential for more than minimal harm

E May 9, 2025 Tag F0695 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

G May 30, 2024 Tag F0600 Complaint investigation Corrected Jun 2024

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.

Actual harm to a resident

B February 8, 2024 Tag F0912 Corrected Mar 2024

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

No actual harm, minimal potential

D February 8, 2024 Tag F0761 Corrected Mar 2024

Pharmacy Service Deficiencies

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, potential for more than minimal harm

D September 26, 2023 Tag F0745 Complaint investigation Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

No actual harm, potential for more than minimal harm

D September 26, 2023 Tag F0658 Complaint investigation Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0921 Corrected Jul 2021

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0912 Corrected Jul 2021

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0814 Corrected Jul 2021

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0806 Corrected Jul 2021

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0803 Corrected Jul 2021

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0761 Corrected Jul 2021

Pharmacy Service Deficiencies

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, potential for more than minimal harm

D June 11, 2021 Tag F0693 Corrected Jul 2021

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0688 Corrected Jul 2021

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.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0584 Corrected Jul 2021

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D June 11, 2021 Tag F0558 Corrected Jul 2021

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E June 11, 2021 Tag F0880 Corrected Jul 2021

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E June 11, 2021 Tag F0812 Corrected Jul 2021

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E June 11, 2021 Tag F0801 Corrected Jul 2021

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

No actual harm, potential for more than minimal harm

E June 11, 2021 Tag F0758 Corrected Jul 2021

Pharmacy Service Deficiencies

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, potential for more than minimal harm

E June 11, 2021 Tag F0755 Corrected Jul 2021

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

E June 11, 2021 Tag F0658 Corrected Jul 2021

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

G June 11, 2021 Tag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Actual harm to a resident

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.