Winning Wheels

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 1, 2024

  Based on interview and record review the facility failed to supervise a resident with exit-seeking behaviors to prevent her from eloping from the building unsupervised. This failure resulted in R1 eloping from the facility and being able to reach a heavily traveled highway. This applies to one of three residents (R1) reviewed for the safety in the sample of 8. The Immediate Jeopardy began on 4/24/24 when R1 was able to elope from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/30/24 at 12:50 PM. […]

• Immediate jeopardy, isolatedF689Oct 20, 2021

  Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident exhibiting exit seeking behaviors was supervised to prevent elopement. The facility also failed to ensure interventions were effective to prevent an elopement for one of three residents (R1) reviewed for elopement in the sample of 3. The Immediate Jeopardy began on 10/12/21 when R1 left the facility grounds undetected. The Immediate Jeopardy was identified on 10/14/21. V1 Administrator was notified of the Immediate Jeopardy on 10/19/21 at 8:44 AM. […]

• Immediate jeopardy, isolatedF600Jan 7, 2021

  Based on interview and record review the facility failed to ensure a resident was free from sexual abuse by V4. These failures resulted in R1 being sexually abused. This applies to one of three residents (R1) reviewed for abuse in the sample of three. The Immediate Jeopardy began on 12/18/20 when the facility received notification that V4 (CNA-Certified Nurse Aide) was having a sexual relationship with a resident. The Immediate Jeopardy was identified on 1/5/21. V1 (Administrator) was notified of the Immediate Jeopardy on 1/7/21 at 10:10 AM. […]

• Actual harm, isolatedF689Feb 5, 2026

  Based on observation, interview, and record review the facility failed to ensure hot liquids were safely served and failed to ensure a process was in place for hot liquids for 1 of 3 residents (R5) reviewed for safety in the sample of 8. This failure resulted in R5 spilling his coffee on his lap and sustaining two partial thickness burns to his left inner knee causing R5 pain.The findings include:R5's face sheet showed his most recent readmission to the facility on 1/11/25 with diagnoses to include acute and chronic respiratory failure with hypoxia, atherosclerotic heart disease, chronic cough, dysphagia, epilepsy, hemiplegia and hemiparesis, and mononeuropathy of left lower limb. […]

• Actual harm, isolatedF689May 27, 2025

  Based on observation, interview and record review the facility failed to ensure safety measures were implemented for three residents (R1, R2, R3) who fell during cares and/or transfers of three residents reviewed for falls. This failure resulted in R1 sustaining a fractured left humerus. The findings include: Facillity Policy/Safety and Supervision, last revision date 02/2025, documents: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. […]