Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Win Post-acute during CMS and state inspections, most recent first.
A resident with BPH, type II DM, and a lumbar compression fracture had a physician order for daily Finasteride 5 mg, but the medication was not administered on two consecutive days. Nursing staff documented in the EMAR that the drug was "awaiting supply," yet the DON later confirmed there was no actual medication shortage and no documentation that staff contacted the pharmacy, used the emergency medication supply, or arranged for emergency delivery as required by facility policy. This failure to follow up and to administer the ordered medication in accordance with professional standards resulted in a cited deficiency.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Three residents received oxygen therapy that did not follow physician orders: one received a higher flow rate than ordered, another was given oxygen without any physician order, and a third received a higher flow rate than prescribed despite multiple medical conditions. Staff and the DON confirmed that oxygen administration did not match the documented orders, contrary to facility policy.
The facility did not complete or document annual performance reviews for 40 out of 69 CNAs employed for over one year, as confirmed by employee file reviews and interviews with the DSD and DON.
A review of controlled medication records revealed that staff failed to consistently document the administration of narcotics in both the Controlled Drug Record (CDR) and Medication Administration Record (MAR). In some cases, medication was given but not signed out in the CDR, while in others, medication was signed out but not recorded on the MAR. The DON confirmed these discrepancies, which resulted in inaccurate accountability of controlled substances.
A resident was administered Midodrine HCl multiple times when their systolic blood pressure was above the physician-ordered threshold, contrary to the medication order and facility policy. An LVN confirmed the medication should have been held in these instances, but it was given on 14 occasions outside the prescribed parameters.
The facility did not identify that 40 of 69 CNAs lacked documented annual performance reviews because required random personnel file audits were not performed or documented, and this deficiency was not detected or addressed through the QAPI monitoring process.
A CNA failed to perform hand hygiene between feeding two residents, contrary to facility policy, and an LVN confirmed that a resident's IV tubing was left uncapped and exposed to air when not in use, both representing failures to follow infection prevention and control procedures.
A resident with Type 2 Diabetes Mellitus and a history of foot issues was observed to have thickened, discolored, and overgrown toenails, with no care plan or medical orders in place for preventive foot care or podiatry services. The DON confirmed the lack of a care plan addressing these needs, despite facility policy requiring comprehensive care planning.
Two residents experienced falls, but their care plans were not updated or revised by the interdisciplinary team as required by facility policy. The DON confirmed that no new interventions or changes were documented in the care plans following these incidents.
A resident with multiple medical conditions and at risk for skin breakdown was not provided with physician-ordered heel protectors, despite having stage 1 pressure ulcers on both heels. Staff confirmed the absence of the protective boots during several observations, and the devices could not be located, resulting in noncompliance with the facility's pressure injury prevention policy.
A bottle of expired Mirtazapine 15 mg was discovered in a medication cart during an inspection, with both an LVN and the DON confirming it should have been removed according to facility policy. Review of procedures showed that expired or discontinued medications are to be secured and marked for destruction, but the expired drug remained in the cart.
Surveyors found that several two-resident rooms provided only 71.5 square feet per resident, below the required 80 square feet. Residents reported no concerns about space, and the Administrator stated that regular checks with residents and families had not identified any issues. The Administrator also noted a room waiver was in place.
A resident with severe cognitive impairment and multiple health issues was found with significant injuries, including facial bruises and chipped teeth, while in bed at an LTC facility. Staff interviews indicated the resident was unable to self-harm or move independently, and the injuries were discovered later in the evening. The resident was hospitalized and later died, with the cause of death determined as blunt force injury of the head, classified as a homicide.
Failure to Follow Up on Ordered Medication and Ensure Administration
Penalty
Summary
The deficiency involved the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice when nursing staff did not follow up on a prescribed medication for one resident. The resident was admitted with diagnoses including benign prostatic hyperplasia (BPH), type II diabetes mellitus, and a wedge compression fracture of the first lumbar vertebra. A physician’s order dated 11/11/25 directed that the resident receive Finasteride 5 mg by mouth once daily for BPH. Review of the Medication Administration Record showed that Finasteride was not administered on 11/12/25 and 11/13/25. The EMAR administration note dated 11/13/25 documented that the Finasteride 5 mg tablet was “awaiting supply.” During interview and concurrent record review, the DON confirmed that the Finasteride doses were not given and that there was no shortage or inadequate supply of the medication. The DON stated that nursing staff had documented the medication as being on order and acknowledged there was no documentation that staff followed up with the pharmacy. Review of the facility’s “Medication Shortages/Unavailable Medications” policy indicated that nurses should call the pharmacy to determine order status, obtain medication from the emergency supply if delivery delays would cause a missed dose, arrange for emergency delivery if not available in the emergency supply, and document any unavoidable missed dose and explanation on the MAR/TAR and in nurse’s notes. These required follow-up and documentation steps were not carried out or documented by nursing staff for this resident’s Finasteride doses.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow professional standards of practice for oxygen administration for three residents. One resident was observed receiving oxygen at a flow rate higher than the physician's order, with the nasal cannula set between 2.5 and 3 liters per minute (LPM) instead of the ordered 2 LPM. Another resident was administered oxygen at 4 LPM without any physician's order for oxygen therapy, as confirmed by both observation and review of the resident's medical orders. A third resident, who had multiple diagnoses including spinal cord injury, diabetes, chronic kidney disease, myelofibrosis, and anemia, was observed receiving oxygen at 4 LPM, while the physician's order specified 2 LPM. In each case, staff acknowledged the discrepancies between the administered oxygen and the physician's orders. The facility's policy and procedure for oxygen administration requires staff to check the physician's order for the correct liter flow and method of administration. Despite this, staff failed to ensure that oxygen was administered according to the prescribed orders for these residents. The Director of Nursing confirmed that oxygen orders should always be followed, and staff interviews further verified that the observed oxygen administration did not match the documented orders.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct and document annual performance reviews for 40 out of 69 Certified Nursing Assistants (CNAs) who had been employed for over one year, as required by federal regulation. During a review of employee files, it was found that no annual performance reviews were documented for multiple CNAs, including those hired as far back as 2017 and 2021. Interviews with the interim Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that there was no evidence of completed annual performance reviews for these staff members, and the current DSD was unaware of the previous process for conducting such reviews. A list compiled by the DON further verified that 40 CNAs had not received their required annual performance evaluations.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents during a random audit. For one resident, Hydrocodone-Acetaminophen was documented as administered on the Medication Administration Record (MAR), but the dose was not signed out on the Controlled Drug Record (CDR). The responsible RN confirmed during interview that the medication was given but the CDR was not signed at the time of administration. For two other residents, controlled medications (Norco and Oxycodone Hydrochloride) were signed out of the CDR, indicating removal from the medication cart, but the administration was not documented on the MAR. The Director of Nursing (DON) acknowledged during interviews that the medications were not properly accounted for in the MAR. A review of the facility's policies confirmed that staff are required to document the administration of controlled substances both in the narcotic book (CDR) and on the MAR, in accordance with applicable law and facility procedures. The failure to consistently document controlled medication administration in both records resulted in inaccurate accountability of these medications.
Failure to Hold Medication per Physician-Ordered Blood Pressure Parameters
Penalty
Summary
A deficiency was identified when a resident received the medication Midodrine HCl outside of the physician-ordered parameters. The resident had an order for Midodrine HCl 5 mg by mouth three times daily for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 120 mmHg. Despite this, the medication administration record (MAR) showed that the resident received Midodrine on multiple occasions when the SBP exceeded 120 mmHg, specifically on five occasions in March and eight occasions in April, as well as once in May. During an interview and record review, an LVN confirmed that the medication should not have been administered when the SBP was above the ordered threshold, acknowledging that the medication was given inappropriately on 14 separate incidents. The facility's medication administration policy required staff to obtain and record vital signs and to hold medications when vital signs were outside the physician's prescribed parameters, which was not followed in these instances.
Failure to Identify Missing CNA Annual Performance Reviews in QAPI Monitoring
Penalty
Summary
The facility failed to identify and address the lack of annual performance reviews for Certified Nursing Assistants (CNAs) within its Quality Assurance Performance Improvement (QAPI) Plan. The QAPI plan, last updated in 2017, required quarterly random personnel file reviews to ensure compliance with training, documentation, and regulatory requirements, with findings to be reported to the QA&A Committee. However, there was no documentation that these random audits of personnel files were performed, and the facility was unaware that annual performance reviews for CNAs were not being completed. As a result, 40 out of 69 CNAs employed by the facility did not have documented annual performance reviews, which was not identified or addressed through the facility's QAPI monitoring process.
Failure to Follow Infection Prevention Practices During Resident Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed feeding two residents during lunch without performing hand hygiene between resident contacts. The CNA stated that she washed her hands prior to feeding but did not clean her hands between feeding two residents at the same time. The facility's hand hygiene policy requires hand hygiene to be performed between resident contacts, which was not followed in this instance. Additionally, a Licensed Vocational Nurse (LVN) confirmed that the tip of a resident's intravenous (IV) tubing was left uncapped and exposed to air when not in use. The resident had a history of post digestive system surgery, severe protein-calorie malnutrition, and a gastrostomy tube, and was receiving IV hydration as ordered by a physician. The facility's infection prevention and control policy requires all staff to follow procedures to prevent infection, which was not adhered to in this case.
Failure to Develop and Implement Preventive Foot Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of foot problems and a diagnosis of Type 2 Diabetes Mellitus. Observations revealed that the resident had skin buildup on both feet, with thickened, discolored, and overgrown toenails. Interviews with a confidential friend indicated concerns about the resident's long toenails and a history of fungal infections, emphasizing the need for preventive foot care to avoid recurrence. A review of the resident's care plan and medical orders showed that there was no care plan or physician order in place for preventive foot care or podiatry services. The Director of Nursing confirmed the absence of a care plan addressing preventive foot care for the resident, despite the facility's policy requiring comprehensive care planning to maintain optimal health and quality of life.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update the care plans for two residents following documented fall incidents. For one resident, a fall occurred on 2/21/25 at 4:30 p.m., but a review of the care plans showed that the last revision was dated 11/25/24, with no updates or new interventions documented after the fall. The Director of Nursing confirmed during an interview that the care plan was not updated following this incident. Facility policies require care plans to be reviewed and revised by the interdisciplinary team after significant changes in condition or incidents such as falls, but this was not followed. Similarly, another resident experienced a fall on 1/12/25 at around 7:40 a.m., but the care plan reviewed on 5/8/25 did not include any updates or interventions related to the fall. The Director of Nursing also confirmed that the care plan was not updated for this incident. The facility's policies and procedures specify that care plans should be modified as necessary after significant events, including falls, but there was no evidence of such revisions in these cases.
Failure to Implement Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
Staff failed to follow physician orders for pressure ulcer prevention for one resident with a history of heart failure, pancytopenia, encephalopathy, and muscle weakness. The resident was identified as at risk for skin breakdown, with a Braden Scale score of 17 and documented stage 1 pressure ulcers on both heels. Physician orders were in place for the application of skin barrier film every shift and for protective boots to be worn on both feet every shift to prevent further skin breakdown. Despite these orders, multiple observations over several days found the resident lying in bed without heel protectors. Interviews with nursing staff confirmed the resident was not wearing the prescribed heel protective boots, and staff were unable to locate the devices in the resident's room. The Director of Nursing also confirmed the existence of the physician's orders and acknowledged that the boots should have been in use. Facility policy required interventions such as offloading heels to prevent pressure injuries, but these were not implemented as ordered.
Expired Medication Found in Medication Cart
Penalty
Summary
A deficiency was identified when a bottle of Mirtazapine 15 mg, used to treat depression, was found in one of the facility's medication carts (med cart AA) with an expiration date that had already passed. During an inspection, a Licensed Vocational Nurse (LVN) confirmed the medication was expired and acknowledged it should have been removed from the cart. The Director of Nursing (DON) also confirmed in an interview that expired medication should not remain in the medication cart. A review of the facility's policies and procedures revealed that discontinued or outdated medications are to be placed in a designated, secure location for destruction, and all medications must be labeled and stored according to state and federal regulations. The facility's policy also requires routine inspection by the consultant pharmacist to identify and remove outdated or deteriorated medications. Despite these policies, the expired medication remained accessible in the medication cart.
Insufficient Square Footage in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident, as required. Observations conducted in nine two-resident rooms revealed that each room measured 13 feet by 11 feet, totaling 143 square feet, which equates to only 71.5 square feet per resident. Residents occupying these rooms reported having sufficient space and did not express concerns regarding room size. During an interview, the Administrator stated that social services regularly inquire about room size concerns with residents and families, and no issues had been reported. The Administrator also indicated that the smaller room size did not interfere with resident care and mentioned the existence of a room waiver.
Resident Suffers Fatal Injuries in LTC Facility
Penalty
Summary
A resident in a long-term care facility was not protected from physical abuse, as evidenced by the discovery of multiple injuries including bruises on the face and arms, swelling on the nose and eyebrow, a cut on the lower lip, blood in the mouth, and chipped teeth. The resident, who had severe cognitive impairment and was dependent on staff for mobility, was found in this condition while in bed. The resident's medical history included significant health issues such as osteomyelitis, COPD, severe malnutrition, muscle weakness, atrial fibrillation, stage 4 pressure ulcer, congestive heart failure, osteoporosis, and osteoarthritis. Interviews with facility staff revealed that the resident was last seen without injuries by a certified nursing assistant (CNA) and registered nurses (RNs) earlier in the evening. The injuries were discovered later that night, and staff members confirmed that the resident did not have behaviors of self-harm and was unable to get out of bed independently. The facility's investigation summary noted that the resident was sent to an acute hospital for further evaluation following the discovery of the injuries. The resident was later declared deceased at the hospital, with the cause of death determined to be blunt force injury of the head, complicating existing cardiovascular conditions. The death was classified as a homicide, with the injuries occurring in the resident's shared room at the facility. The facility's policy on abuse and crime reporting emphasized the residents' right to be free from abuse, highlighting a failure to protect this resident from harm.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Santa Clara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skyline Healthcare Center - San Jose | 0.7 mi | ★★★★★ | 1 | 0 |
| O'connor Hospital D/p Snf | 0.7 mi | ★★★★★ | 8 | 0 |
| Courtyard Care Center | 1.4 mi | ★★★★★ | 2 | 0 |
| White Blossom Care Center | 2 mi | ★★★★★ | 22 | 0 |
| A Grace Sub Acute & Skilled Care | 2.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.