Winkler Court

In the surveyor’s words

From the most serious findings on record at Winkler Court, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 16, 2024

  Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect by failing to ensure full body mechanical lifts were in safe operating condition, failing to ensure staff followed safety protocol when using mechanical lifts, and failure to ensure staff responsible for the inspection and maintenance of mechanical lifts was knowledgeable and competent to perform the job duties. Resident #1 was dependent on staff and required the use of a mechanical lift for transfer. […]

• Immediate jeopardy, patternF689Feb 16, 2024

  Based on observation, record review, review of facility's policies and procedures, and staff interviews, the facility failed to implement processes to prevent accidents by failing to ensure staff followed manufacturer's safety recommendations during transfer with mechanical lift, and failing to ensure mechanical lifts were in safe operating condition. On 1/22/24 staff used a full body mechanical lift to transfer Resident #1. The motor of the lift had been removed making the locking mechanism inoperable. Resident #1 fell from the lift, sustained cuts to the left arm, complained of head trauma and pain all over. Resident #1 required an emergent transfer to an acute care hospital for evaluation and treatment. […]

• Immediate jeopardy, patternF908Feb 16, 2024

  Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure resident equipment was in safe operating condition. On 1/22/24 Staff used a full body mechanical lift to transfer Resident #1. Resident #1 fell from the mechanical lift, sustained cuts, complained of head trauma and generalized pain requiring an emergent transfer to an acute care hospital. The motor of the lift had been removed since July 2023 causing the legs of the base to not lock to ensure a safe transfer. Staff responsible for the inspection and maintenance of the mechanical lifts did not have the training and competency to ensure the mechanical lifts were in safe operating condition. […]

• Immediate jeopardy, isolatedF835Feb 16, 2024

  Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect by failing to ensure staff competency in the areas of inspecting, identifying, and removing unsafe resident equipment from use, and safe transfer techniques with mechanical lifts. On 1/22/24 Staff used a full body mechanical lift to transfer Resident #1. The motor of the lift had been removed since July 2023 causing the legs of the base to not lock to ensure a safe transfer. Resident #1 fell from the mechanical lift, sustained cuts, complained of head trauma and generalized pain requiring an emergent transfer to an acute care hospital. […]

• Actual harm, isolatedF686Aug 19, 2026

  Based on record review, facility policy review and staff interviews, the facility failed to monitor skin integrity and treat skin ulceration related to the use of a splinting device for 1 (Resident #1) of 3 residents reviewed, resulting in the development and worsening of an avoidable pressure ulcer.The findings included:Review of the facility provided Wound Prevention Treatment and Overview Policy and Procedure with an effective date of August 2026 revealed, The facility strives to ensure that a resident entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. […]