Winston Manor Cnv & Nursing

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide clean bathrooms and an environment free of urine, feces and body odors. This applies to 15 residents (R1, R2, R3 and R6 through R17) of 17 in the sample reviewed for safe, clean and homelike environment.

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure the confidentiality and security of residents' medical records. This failure has the potential to affect all 143 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure medications were locked and secured while unattended, b.) ensure controlled substance medications were double-locked and secured while unattended, and c.) properly waste and discard expired medications and controlled substance medications. These failures have the potential to affect all 143 residents residing in the facility reviewed for medications stored in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that two residents (R3 and R14) were free from verbal abuse. This failure has affected two of four residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the residents' bathroom floor was dry and free of a liquid substance. This failure has resulted in one resident (R1) slipping on the bathroom floor and sustaining fractures to her ankle.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a homelike environment for the residents. This failure applies to all 139 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to prevent resident to resident verbal and physical abuse for one [R1] out of three residents reviewed for abuse. This resulted in R1 sustaining physical pain and mental anguish. Findings Include: R1's clinical record indicates the following in part: R1's medical diagnoses of post -traumatic stress disorder, chronic obstructive pulmonary disease, anxiety disorder, schizoaffective disorder, and overactive bladder. R2's clinical record indicates the following in part: Medical diagnoses: Schizoaffective disorder and major depressive disorder. R2's progress notes in part:V6 [Licensed Practical Nurse] note:12/26/2025 3:46 AM Note Text: This writer heard loud yelling in R2's room around 1:45 AM. R2 noted to be verbally aggressive with her roommate [R1]. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse Reporting Policy and report allegations of abuse within two hours of the incident for one [R1] out of three residents reviewed for abuse. Findings Include: Reviewed facility's IDPH Initial Report for incident 12/26/25 [R1and R2]. Dated: 12/30/25Time: 10:33 [NAME] 12/30/25 at 11:40 AM, R1 stated, On Christmas night, I was sleeping when my roommate [R2] hit me all in my back, everywhere on my body. Then R2 started throwing items at me, and some of the items hit me on my arm. R2 was cursing at me and yelling, she called me names I never been called before. I finally was able to get out of bed, and then I was yelling and screaming for help. I got out of bed and grabbed my walking cane to help me walk so I could get out of the room. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a homelike environment for two (R3 and R4) out of three residents reviewed for homelike environment in a total sample of 4 residents.

Inspectors wroteBased upon interviews and record review the facility failed to: conduct head counts (every two hours); failed to provide supervision for one resident (R7) in the sample; failed to follow Doctor's pass order for one resident (R5); and failed to implement the elopement and pass policies for three residents in a sample of 15 (R5, R6 and R7). These failures resulted in an immediate jeopardy and has the potential to affect 123 residents that reside in the facility. An immediate jeopardy began on 8/9/25 at 9:00 am, when R6 left the facility unauthorized and continued with subsequent failures that led to R5 and R7 also being away unauthorized. On 8/14/25 at 3: 47.pm, V1 (Administrator) and V20 (Regional Consultant) were notified of the Immediate Jeopardy and the IJ template was presented. [...]

Inspectors wroteBased on interviews and record review, the facility failed to report that one newly admitted resident (R7) eloped from the facility; and failed to report that two residents (R5 and R6) left the facility unauthorized and did not return to the facility. This failure has affected three of fifteen residents in the sample and has the potential to affect all 123 residents that reside in the facility. R5 is a [AGE] year-old male with diagnoses of Schizophrenia, schizoaffective disorder, essential hypertension, tachycardia, and chronic obstructive pulmonary disease. R6 is a [AGE] year-old male with diagnoses of schizoaffective disorder, suicidal ideations, acute embolism, and thrombosis of unspecified deep veins of bilateral lower extremity, Gastro-esophageal reflux disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered behavior care plan to address the resident's mental and psychosocial needs in an effort to attain or maintain the resident's highest practicable mental and psychosocial well-being. This failure affected 1 (R8) resident reviewed for care planning in the total sample of 15 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that COVID vaccinations, consents and education were documented for four residents. This failure has the ability to affect all 122 residents that reside in the facility.

Inspectors wroteBased on interview and document review the facility failed assure the resident right to be free of physical abuse in 1 of 3 (R1) residents in a total sample of 8 residents. This failure resulted in R1 having bleeding lips, bump to right temporal area and feelings of fearing for his life.

Inspectors wroteBased on interview and record review the facility failed to follow their elopement policy and procedure consistently with professional standards of practice placing the resident's health and safety at risk for one (R1) resident out of three residents reviewed in a total sample of three.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from physical abuse. This failure affected 2 (R1 and R2) out of 7 residents reviewed for abuse. R1 and R2 had a brawling incident on 3/28/25 that resulted in R2 having a nosebleed.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse prevention program policy and procedure to check and review the criminal history background check within 24 hours of admission for one (R2) out of seven residents reviewed for abuse, and to ensure two staff (V8, V16) were educated and fully understood their abuse prevention program policy and procedure. This failure had the potential to affect all 48 residents residing on the fourth-floor unit. Finding Include: On 4/20/25 at 9:32 AM, interviewed V8 (Agency Licensed Practical Nurse) and stated she is the nurse in charged on the fourth floor. V8 stated it's her first day in the facility. Surveyor asked V8 about the facility's abuse policy. V8 stated she does not know who the abuse coordinator is and who to report abuse to. V8 stated she never received any abuse in-service or education. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident from staff to resident abuse. This failure affects one (R2) resident out of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility policy regarding wearing personal protective equipment (PPE) during manual handling of linen during sorting/rinsing and storing clean linen in a protected area. This failure has the potential to affect all 77 residents residing in the facility based on daily census dated 06/24/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe environment by not providing covers or guards for florescent tube lights located in over the head wall lights behind resident's bed. These failures affected seven residents (R8, R22, R36, R39, R46, R55, R70) when reviewed for environment in the sample of 21 residents.

Inspectors wroteBased on interview and record review, the facility failed to communicate to the primary physician and follow Neurology recommendation for 1 (R7) resident out of the final sample of 21. Findings Include: R7's electronic health records show R7 has diagnoses not limited to Schizoaffective Disorders, Schizophrenia, and Drug Induced Subacute Dyskinesia. R7's physician orders show R7 is receiving antipsychotic medication Clozapine. R7's Neurology Clinic's AFTER VISIT SUMMARY dated 4/9/24 shows R7 was examined by V24 (Medical Doctor) for Tardive Dyskinesia and recommended speech therapy for R7. R7's physician orders from April 2024 does not show a referral for Speech Therapy was ordered. R7's progress notes dated 4/9/24 at 1:06 PM reads, resident came back without follow up apt. No documentation that shows V24's recommendation was communicated and followed-up with V25 (Primary Physician). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required 80 square feet per bed for 5 resident rooms out of 68 resident rooms in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy for Advance Directives by not obtaining physician orders for two (R6, R44) residents and not addressing on the resident's plan of care, physician progress notes, physician's orders and in social service progress notes for 11 (R3, R6, R13, R14, R20, R24, R52, R54, R57, R65, R321) residents. These failures can potentially affect 13 residents in a sample of 22 reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility (A) failed to ensure wheelchairs for two [R18, R21] residents were maintained to protect their safety, and (B) failed to ensure ceiling paint was free from watermarks, peeling falling paint in one [R11] resident's room, and the second-floor shower room. These failures have the potential to affect all 34 residents residing on the second floor.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow policy for comprehensive care plan to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's needs and problems for 13 (R3, R6, R13, R14, R20, R24, R42, R44, R52, R54, R57, R65, R321) residents reviewed for comprehensive care plan in a sample of 22.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and cover clean laundry with a clean protective sheet. This has the potential to affect all 31 residents that reside on the fourth floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a functioning call light communication system was accessible to 3 residents (R12, R14, R68) of 22 residents reviewed. This failure has the potential to effect 34 residents residing on the second floor.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide effective pest control two [R11, R32] residents in the sample of 22. These failures have the potential to affect all 34 residents residing on the second floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within the residents reach for 2 (R14, R24) residents reviewed for accommodation of needs in a sample of 22. Findings Include: On 05/16/23 at 10:52 AM upon entering R14s room R14 was observed lying in bed with the call light located behind the headboard over the head of the bed. Surveyor asked R14 where the call light was located? R14 responded to tell you the truth, I don't know where the call light is. A few days ago, I fell, ended up on my knees and I called out for help. On 05/16/23 at 11:00 AM V4 (Certified Nurse Assistant) stated When I am making my rounds, I am checking to make sure everyone is ok, not harmed, awake or sleeping, if they are breathing, need assistance or need anything. I make rounds every 2 hours. R14 is supposed to use the call light. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to identify and evaluate hazard(s) and risk(s) by not completing resident smoking safety risk assessments to ensure the environment is free from accident hazards. This failure can potentially affect two (R42 and R44) residents reviewed for smoking in a sample of 22.

Inspectors wroteBased on observations and interviews, the facility failed to provide the required 80 square feet per bed for 5 resident rooms out of 68 resident rooms in the facility. This failure has the potential to affect six residents (R26, R27, R30, R39, R48, R67).

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy and physician order related to applying left wrist splint for a resident diagnosed with Arthritis and De Quervain's Tenosynovitis (inflammation of tendons) to 1 of 1 resident (R33) for a total sample of 19 reviewed. Failures include: On 07/26/2022 from 10:20 AM to 01:16 PM V11 (Registered Nurse) stated, R33 is able to ambulate and with no limitation in moving his extremities. R33 stated that he has no concern as to his range of motion. R33 does not have his splint applied when seen from 10:20 AM till present. On 07/27/2022 at 09:48 AM. R33 was seen without left wrist/hand splint at 2nd Floor dining room while playing bingo. On 07/27/2022 at 11:22 AM. V4 (Registered Nurse) was informed that since yesterday morning R33 was seen without a splint on his left hand. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy and physician order related to CPAP (Continuous Positive Airway Pressure) treatment to a resident diagnosed with Sleep Apnea (absence of breathing during sleep) to 1 of 1 residents (R33) for a total sample of 19 reviewed. This failure has the potential to affect 1 of 1 residents at risk for Sleep Apnea untreated.

Inspectors wroteBased on observations and interview, the facility failed to provide the required 80 square feet per bed for five resident rooms.