Federal inspectors found the nursing home violated its own Fall Prevention Program, which states that "malfunctioning equipment will be immediately reported to maintenance for repair or removed from service." The facility's transfer policy similarly requires routine maintenance checks "to ensure that equipment remains in good working order."
The equipment manufacturer's manual warns that "bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury" and instructs staff to "discard immediately" any damaged lift pads. The manual also cautions that before moving patients, staff must "check again to make sure that the sling is properly connected" and warns that improper attachments could cause falls.
The inspection found actual harm to residents, though the facility had already begun corrective measures before the January 29 survey.
On October 27, 2025, the nursing home conducted a facility-wide audit to inspect all mechanical lift pads for damage. That same day, a certified nursing assistant received formal training on mechanical lift transfers and sling functions.
Between October 26 and November 4, 2025, all certified nursing assistants received training on proper transfer techniques and lift pad inspection, with required competency demonstrations.
The facility implemented ongoing monitoring requiring the Director of Nursing to observe five residents during transfers three times weekly for four weeks, then monthly thereafter. The Administrator began similar observations of two laundry staff members on the same schedule.
Quality assurance meetings in November 2025 and January 2026 reviewed the corrective plan with the Medical Director, Administrator, and Director of Nursing.
The nursing home's Fall Prevention Program aims "to assure the safety of all residents in the facility, when possible" through proper assessment of fall risks and implementation of appropriate safety measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Care Windsor Park from 2026-01-29 including all violations, facility responses, and corrective action plans.