Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Winston Manor Cnv & Nursing during CMS and state inspections, most recent first.
The facility failed to maintain confidentiality of PHI when large volumes of resident medical records were stored in an unsecured, cluttered basement gym area. Unsealed boxes of records, with papers containing identifying medical and personal information spilling onto the floor, were placed randomly among other stored items. The staff member overseeing medical records reported that he thins charts and stores them in this gym, acknowledging that records are scattered and exposed. The maintenance director stated that housekeeping and maintenance staff routinely access this area and that the door, though lockable, was sometimes propped open and left unlocked, allowing any staff nearby to enter and view records. The administrator confirmed that records are not supposed to be accessible to staff not involved in resident care, and facility policies require PHI protection and locked storage of medical records.
Surveyors found that medications, including resident-specific bingo cards and controlled substances such as Lorazepam, were stored in an unlocked basement area accessible to multiple staff. The basement door was not kept locked, and medication cards with resident names and expired drugs were observed in open boxes and on the floor. The DON acknowledged that these medications, including controlled substances, should have been stored in a locked medication room with narcotics double-locked. An RN described the expected process for returning and destroying medications, and the Maintenance Director confirmed that the basement had long been used as storage and that he had seen resident medication bingo cards there, contrary to facility policies requiring secure, restricted access and proper disposal of medications.
Two cognitively intact residents with psychiatric and medical conditions reported that another resident repeatedly entered or roamed their units, followed them, entered a room at night, and directed sexually explicit, demeaning, and threatening language toward them, including threats of physical harm and sexually violent acts. Multiple agency RNs confirmed that this resident frequently came onto a different floor, harassed female residents, made sexually inappropriate remarks, yelled, used derogatory names, and made threats despite redirection attempts. Nursing notes documented the resident’s agitation, aggressive behavior, and harassment of a female resident, while leadership and facility policy acknowledged residents’ rights to be free from verbal and sexual abuse and harassment by anyone in the facility.
A resident with multiple comorbidities and intact cognition slipped and fell in a hallway bathroom after entering a dark room with a very wet floor and no wet floor signage, resulting in a left ankle trimalleolar fracture. The DON reported being told by the agency RN that the bathroom floor was wet, and stated she expected staff to remove the water and post a wet floor sign. A NP confirmed that liquid on the floor is a fall risk, and the unwitnessed fall report documented the RN finding the resident on the bathroom floor after hearing calls for help. Facility housekeeping duties included cleaning and wet mopping floors with proper safety precautions, but the bathroom floor remained wet at the time of the incident.
The facility failed to maintain resident bathrooms and shower rooms in a safe, clean, and homelike condition. A resident reported that bathrooms and shower rooms were dirty, sometimes lacked shower curtains, and had peeling drywall. Surveyors observed black and brown buildup on shower walls on multiple floors, peeling paint and drywall, a hole in a shower room ceiling, a third-floor restroom with a hole in the wall and a roll of paper towels placed on a garbage can instead of in a dispenser, a missing toilet seat in a second-floor shower room stall, and a torn, stained shower curtain and dirty light fixture in a fourth-floor shower room. Staff interviews confirmed that housekeeping was supposed to scrub showers daily, that these conditions were uncomfortable and unsanitary, and that maintenance and housekeeping were responsible under facility policies for keeping the building in good repair and providing thorough housekeeping services to support a homelike environment.
A resident with multiple psychiatric diagnoses was physically and verbally attacked by her roommate, who also has a history of psychiatric disorders. The aggressor hit the resident, threw items, and attempted to use her cane as a weapon, causing physical pain and emotional distress. Staff responses were inconsistent, with some not recognizing or reporting the abuse, and facility leadership did not fully investigate or document the incident until days later, contrary to facility policy requiring immediate reporting and investigation.
A resident was physically attacked by her roommate, involving hitting and objects being thrown, and staff intervened to separate them. Despite witnessing the incident, staff did not report the abuse within the required two-hour timeframe, and facility leadership was not fully aware of the severity until days later, resulting in delayed notification to authorities.
Two residents were found living in rooms with significant maintenance issues, including water leaks, holes in walls and ceilings, musty odors, and exposed rusty metal. Despite being reported to maintenance staff, these problems remained unaddressed for over a month, resulting in unsafe and non-homelike living conditions.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
Three residents left the facility without authorization, including one who eloped during a smoke break and two who did not return after leaving, despite one having no pass privileges. Staff communicated internally and contacted police, but failed to report these incidents to the State Agency or complete required incident reports, in violation of facility policy.
A resident with schizoaffective disorder, depression, and mild intellectual disabilities exhibited repeated maladaptive and aggressive behaviors, including anger and physical outbursts. Despite these ongoing issues, staff did not develop a person-centered behavior care plan until prompted by a surveyor, rather than at the time the behaviors were first observed, contrary to facility policy.
The facility did not document COVID-19 vaccination status, consent, or education for several residents with complex medical conditions, despite policy requirements. Leadership and staff interviews revealed inconsistent processes for tracking and auditing immunization records, with missing documentation and unclear procedures following leadership changes and a transition to electronic records.
A resident with multiple mental health diagnoses was physically assaulted by another resident, resulting in a bleeding lip, head injury, and emotional trauma. The incident occurred in the dining area, where staff were present but did not intervene. The assaulted resident's roommate stopped the attack, and the resident reported the incident to the DON. Nursing staff provided immediate care, and the physician was notified. The facility's abuse prevention policy was not upheld in this case.
A resident with a history of schizophrenia, depression, and nicotine dependence eloped from an unenclosed smoking area during a monitored break. The staff member present did not immediately notify management or initiate the required emergency response, instead informing the receptionist after the fact. The resident was later returned by police and was physically and verbally aggressive upon return, indicating a failure to follow facility elopement procedures and placing the resident's safety at risk.
Two residents with histories of mental health disorders and aggressive behavior engaged in two separate physical altercations in the facility's lobby, resulting in injuries including a bloody nose and back pain. Despite staff intervention after the first fight, both individuals were kept in proximity, leading to a second altercation. Staff interviews revealed a lack of specific training and procedures for handling abuse situations, and facility policies requiring prevention of abuse were not effectively implemented.
The facility did not follow its abuse prevention policy by failing to review a resident's criminal background check within the required timeframe and not ensuring that an agency LPN and the Maintenance Director were educated on abuse prevention procedures. This lack of compliance contributed to two physical altercations between residents with mental health diagnoses, as staff were unprepared to prevent or manage the incidents.
A resident with schizophrenia and ADHD, who was cognitively intact and required supervision, was not protected from staff-to-resident abuse when a Social Services Director allegedly pulled a chair from under the resident, causing a fall. Witnesses reported the incident as abuse, but it was not promptly reported to the DON or Administrator, resulting in a failure to follow abuse prevention and reporting policies.
The facility failed to follow its infection control policy by not providing gowns for laundry staff handling soiled linen, and by not storing clean linen in a protected area. A staff member only wore gloves, and a large fan blew air across both dirty and clean areas, which were not physically separated, risking cross-contamination.
A facility failed to provide a safe environment by not installing covers on fluorescent tube lights in residents' rooms, affecting seven residents. The exposed lights posed a risk of injury, as residents had to touch the bulbs to turn them on, and the tubes were covered in dust. The Maintenance Director acknowledged the safety concerns, confirming that the lights should have protective covers to prevent hazards.
A resident with intact cognition and multiple medical conditions, including diabetes, was found to have excessively long toenails due to the facility's failure to provide regular podiatry care as per policy. Despite the resident's requests and the facility's policy that only a podiatrist should cut toenails, the resident was only seen once by the podiatrist since admission. Staff interviews and record reviews revealed inconsistencies in documenting podiatry service refusals.
A facility failed to communicate a neurologist's recommendation for speech therapy to a resident's primary physician, resulting in the resident not receiving the recommended therapy. The resident, diagnosed with Schizoaffective Disorders and Tardive Dyskinesia, was on Clozapine. The facility's protocol requires such recommendations to be communicated and documented, but this was not done.
A resident was prescribed antibiotics without proper documentation or indication, violating the facility's antibiotic stewardship program. Staff were unclear about the rationale for the prescription, and vital signs were not monitored as required. The resident was unaware of the reason for the antibiotic treatment.
The facility did not meet the required 80 square feet per bed for five rooms. The Administrator confirmed the deficiency, and a surveyor inspection revealed that four rooms were unoccupied, while one was occupied by three residents who had no concerns. The facility had a waiver from the Illinois Department of Public Health for these rooms.
Improper Storage and Access to Resident Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality and security of residents' medical records when large quantities of records were stored in an unsecured, disorganized basement area referred to as the gym. During a tour of this area with the staff member responsible for medical records and transportation, surveyors observed numerous unsealed boxes filled with medical records placed randomly around the room, with papers spilling out onto the floor. These documents contained identifying personal and medical information for residents from various dates of their stays at the facility. The gym was described as disorganized and cluttered with boxes and miscellaneous items. The medical records staff member stated that he thins resident charts when they become too full and then places the thinned charts into boxes stored in the gym, acknowledging that the records were not stored properly and that residents' personal information was exposed. The maintenance director stated that the basement gym is used as a general storage area for old medical records, broken furniture, and other items, and that he found it in this condition when he started employment eight months earlier. He reported that housekeeping and maintenance staff, totaling ten individuals, have access to the gym and that the door, although equipped with a lock, had been propped open and left unlocked while he was working there and when he went to lunch, allowing any staff in nearby areas such as the kitchen, laundry, and staff locker rooms to enter and view resident records. The administrator stated that he also found the gym full of stored items, including medical records, when he began working at the facility and confirmed that medical records are not supposed to be accessible to staff who are not caring for the residents. Facility policies require that PHI be protected from unauthorized access and that medical records be stored in a locked room, but the observed storage and access practices in the gym did not comply with these policies.
Unsecured Storage and Improper Handling of Resident Medications and Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were stored securely and in accordance with professional standards and facility policy. A staff member responsible for medical records and transportation reported that residents’ medications were being stored in the basement in an unlocked room accessible to all staff, contrary to the requirement that only authorized personnel have access. The basement door, located near the kitchen and laundry room, was observed by the surveyor to be unlocked and opened without a key or access code. Inside the basement, which functioned as an open auditorium/gym area used for storage, multiple boxes containing medication bingo cards with resident names were observed, confirming that resident-specific medications were being stored there. During the same observation, the DON and the medical records/transportation staff member confirmed the presence of multiple medication bingo cards in the basement. The DON picked up a bingo card from the floor that identified a resident by name and listed Aciphex with a dispense date of 02/20/2010 and an expiration date of 02/18/2011, indicating that expired medications were present and not properly discarded. Additionally, three vials of Lorazepam, identified by the DON as a controlled substance, were observed lying on top of a box in the basement with expiration dates of 10/2003, 12/2004, and 04/2005. These observations showed that both non-controlled and controlled medications, including long-expired drugs, were stored in an unsecured, non-clinical area and not managed in accordance with the facility’s policies. Interviews with the DON, an RN, and the Maintenance Director further described the circumstances leading to the deficiency. The DON stated that resident medications should be stored in a locked medication room and that controlled substances should be double-locked, acknowledging that Lorazepam should not be stored in the basement unlocked and unattended. She reported that she had not been in the basement for a long time and was unaware that resident medications were being stored there, suggesting this was a prior facility practice. The RN explained that the usual process for returning medications involved sealed bags sent back to the pharmacy and that controlled substances to be destroyed were handled by the DON, reiterating that all medications should be locked and narcotics double-locked. The Maintenance Director stated that the basement had been used as storage since he started eight months earlier, that the door had a lock but was not kept locked, and that he had seen resident medication bingo cards there. Facility policies dated 09/01/2024 required all drugs and biologicals to be stored safely and securely, with controlled substances kept in locked containers separate from non-controlled medications and access limited to authorized licensed nursing and pharmacy personnel, which was not followed in these instances.
Failure to Protect Residents From Verbal and Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from verbal and sexual abuse by another resident, identified as R4. R3, with schizophrenia, generalized anxiety disorder, neuralgia and neuritis, and a BIMS score of 14, reported that R4 followed him in the hallway, asked to use his laptop and headphones, and later entered his room around 2:00 a.m., calling him a “b****” and telling him to perform a sexual act when R3 told him to leave. R3 stated that R4 told him he could come into his room if he wanted to and that, after being sent to the hospital and returning, R4 again came into his room around 2:00 a.m. R4’s nursing progress notes documented agitation, aggressive behavior, and that he went to another floor to harass a female resident. R14, with major depressive disorder, schizoaffective disorder, essential hypertension, hidradenitis suppurativa, and a BIMS score of 15, reported that R4, newly admitted, came onto her unit where he did not belong and made sexual remarks about his penis size and wanting someone to perform oral sex at the nurses’ station. She stated that when staff told R4 he could not take snacks from that unit, he became aggressive, called them “bitches,” made threats to kill them, and repeatedly left and returned to the unit. R14 further reported that during a meal in the dining room, R4 got in her face, motioned toward her with a balled fist, called her a “fat bitch,” threatened to shove a cane into her buttocks, and stated proudly that he was a pedophile when she told him he was acting like one. She also reported that he continued roaming her floor after bedtime and attempted to follow her to see which room she was going to until a nurse intervened. Staff interviews corroborated that R4 repeatedly came to the second floor, where female residents including R3 and R14 were located, and made inappropriate and threatening remarks. An agency RN (V13) stated that R4 was pacing, unable to be redirected, and was reported to be harassing female residents on another floor, becoming loud and aggressive. Another agency RN (V6) reported that R4 came to the second floor several times, made inappropriate remarks to R3 and R14, refused multiple redirection attempts to return to his own unit, and then began yelling, calling them “bitches,” and threatening to punch them in the face before eventually returning to his floor. The DON acknowledged that residents have a right not to be harassed or verbally assaulted and that all residents should feel safe. Facility policy states that residents have the right to be free from abuse, including verbal and sexual abuse, and that administration is responsible for protecting residents from abuse by anyone, including other residents.
Failure to Maintain Dry Bathroom Floor Leads to Resident Fall and Ankle Fracture
Penalty
Summary
The facility failed to ensure that a resident bathroom floor was dry and free of liquid, resulting in a fall with injury. A cognitively intact, morbidly obese resident with epilepsy, vitamin D deficiency, type 2 diabetes mellitus, and hypertension reported that she was walking from her bedroom to a hallway bathroom in the early morning hours when she entered a dark bathroom with no light on and no wet floor sign present. She stated the bathroom floor was very wet with water, and she slipped, fell, and called for help. Staff responded, and CNAs called 911; EMTs transferred her to the hospital, where imaging showed a left ankle trimalleolar fracture with mild posterior displacement of distal fibula fracture fragments, along with deformity, ecchymosis, tenderness, and decreased range of motion. The DON stated she was informed that the resident slipped and fell on water on the bathroom floor and that the agency RN assigned to the resident that night had reported the bathroom floor was wet. The DON also stated she would expect nursing staff to remove the water from the floor and place a wet floor sign to prevent a patient from falling. A nurse practitioner stated that fall prevention should be in place for all residents, that floors should be free of waste, rugs, or carpets, and that liquid on the floor is a fall risk because residents can slip and fall on it. The unwitnessed fall report documented that the RN heard someone calling for help from the bathroom and found the resident on the floor, reporting pain and exhibiting a limp left foot. The facility’s housekeeper job description included cleaning floors, including damp/wet mopping and disinfecting, in accordance with proper safety precautions, but the report documents that the bathroom floor remained wet at the time of the resident’s fall.
Failure to Maintain Clean, Homelike Resident Bathrooms and Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment in resident bathrooms and shower rooms, affecting all 139 residents. A resident reported that bathrooms and shower rooms were terrible, did not seem up to code, were not cleaned, sometimes lacked shower curtains, and had peeling drywall. During a tour of the second, third, and fourth floor shower rooms, the surveyor observed black and brown substances on shower walls on all three floors and a hole in a shower room ceiling with drywall and paint peeling from the ceiling and walls. Further observations showed additional environmental deficiencies. In a third-floor unisex restroom, the surveyor observed a hole in the wall behind the restroom door and a roll of paper towels used for hand drying sitting on top of a garbage can instead of in a paper towel holder. In the second-floor shower room, the first toilet stall was missing a toilet seat, although the toilet itself was functional. In the fourth-floor shower room, the surveyor observed a torn white shower curtain with black spots and a ceiling light fixture with a black stringy substance adhering to the fixture and ceiling. Interviews with staff confirmed awareness of these conditions and their inconsistency with a homelike environment. The Maintenance Director stated that the black substance on the shower walls was likely soap, grime, or rust buildup and acknowledged that residents may not feel comfortable showering in rooms with peeling paint and dark spots. A housekeeper stated that housekeeping staff are supposed to scrub showers daily to prevent the black substance and acknowledged that it looks uncomfortable. The Maintenance Technician and Maintenance Director both recognized that the hole in the restroom wall and the paper towel roll on the garbage can did not represent a homelike or sanitary environment. The Maintenance Director also acknowledged the missing toilet seat and stated that they would not want a toilet at home without a seat. Facility policies and job descriptions reviewed by the surveyor documented that maintenance and housekeeping are responsible for maintaining the building in good repair, free from hazards, and providing routine and thorough housekeeping services to promote resident comfort and a homelike environment.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident verbal and physical abuse involving one resident with a history of post-traumatic stress disorder, anxiety, schizoaffective disorder, and other medical conditions. The incident involved another resident with schizoaffective and major depressive disorders, who became verbally and physically aggressive during the night, pulling back privacy curtains, playing loud music, turning on bright lights, and ultimately physically attacking her roommate. The aggressor hit the roommate multiple times, threw personal items at her, and attempted to take her walking cane to use as a weapon. The victim reported experiencing significant physical pain, mental anguish, and fear following the attack, stating she was sore for a week and afraid to sleep. Staff responses to the incident were inconsistent and inadequate. One CNA witnessed the argument but did not report it, believing it was not abuse. Another CNA and an LPN intervened during the physical altercation, separating the residents and removing the victim from the room. However, there was confusion and inaccuracy in the documentation of witness statements, with one CNA denying authorship of a written statement attributed to her and stating she was never asked for her account of the incident. The facility's Director of Nursing and Administrator were notified of the incident but did not fully investigate or ascertain the extent of the physical abuse until several days later. Neither asked the victim if she had been physically struck or injured during their initial follow-up. The facility's abuse policy requires immediate reporting and thorough investigation of suspected abuse, but these procedures were not followed. The incident was not promptly or accurately reported to the appropriate authorities, and the severity of the abuse was not recognized or documented in a timely manner. The lack of immediate and thorough investigation, as well as the failure to recognize and report the abuse, resulted in the resident experiencing ongoing pain and emotional distress.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Reporting Policy by not reporting an allegation of resident-to-resident physical abuse within the required two-hour timeframe. On the night in question, one resident was physically attacked by her roommate, who hit her multiple times, threw objects at her, and attempted to strike her with a cane. The incident was witnessed by multiple staff members, including a Certified Nurse Assistant and an Agency-Certified Nurse Assistant, who intervened to separate the residents. Despite the severity of the incident, including the involvement of law enforcement and the removal of the aggressor to a hospital for psychiatric evaluation, the event was not reported to the appropriate authorities within the mandated period. Interviews with staff revealed a lack of immediate recognition and reporting of the abuse. The Certified Nurse Assistant present did not report the altercation, perceiving it as minor arguing, while the Agency-Certified Nurse Assistant confirmed witnessing physical violence. The Director of Nursing and Administrator were not fully informed of the extent of the incident until several days later, and the required report to the state agency was delayed. The facility's policy clearly defines immediate reporting as within two hours, but this protocol was not followed, resulting in a delay in notifying authorities about the abuse allegation.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's room had a hole in the ceiling, chipped paint, a musty odor, and a blue blanket placed on the floor to collect water from a leak that occurred when it rained. The resident reported having informed the Maintenance Director about the issue, but no repairs had been made. The Maintenance Director confirmed being aware of the water leak for approximately one and a half months and had notified the Regional Maintenance Director, but no vendors had come to address the problem. The Maintenance Director also stated that no residents should be living in the room under these conditions and that a room change was necessary. In another case, a different resident's room had a large hole in the wall with exposed rusty metal and chipped paint throughout the ceiling. The resident stated that someone had started repairs but did not return to complete the work. The Maintenance Director explained that the painter responsible for the repairs was let go and no one else had been assigned to finish the job. The Regional Maintenance Director was aware of the ongoing issues and had attempted to patch the roof without success. Both maintenance staff confirmed that the rooms were not safe for occupancy until repairs were completed. The facility's policy requires a safe, clean, and homelike environment, which was not maintained in these instances.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report Unauthorized Departures and Elopement
Penalty
Summary
The facility failed to timely report incidents involving three residents who left the facility without authorization. One newly admitted resident eloped during a smoke break, while two other residents left the facility—one on a pass and did not return, and another left alone despite having an active physician order prohibiting unsupervised passes. The administrator confirmed that the police were contacted regarding the missing residents, but also stated unawareness of the requirement to report missing residents to the State Agency. Documentation revealed that the facility did not complete or submit incident reports for these events as required by their own policy, and the reportable binder contained no records of these incidents. Interviews and record reviews indicated that staff were aware of the residents' absences and communicated internally, but failed to follow through with external reporting obligations. Nursing notes and sign-out sheets documented the residents' departures and lack of return, but there was no evidence of timely notification to the State Agency. Additionally, the medical chart for the resident who eloped lacked an elopement assessment or care plan. The facility's policy requires all accidents or incidents to be investigated and reported to the administrator, with incident reports to be completed and submitted to the DON within 24 hours, which was not done in these cases.
Failure to Timely Develop Person-Centered Behavior Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered behavior care plan to address a resident's mental and psychosocial needs, specifically for a resident with schizoaffective disorder, depression, and mild intellectual disabilities. The resident exhibited a history of dysfunctional behavior, including anger, agitated depression, and restless or agitated actions such as rocking, picking, and banging. Despite these behaviors and a specific incident where the resident kicked a door after becoming upset, the facility did not initiate a behavior care plan until prompted by a surveyor. The care plan addressing inappropriate and maladaptive behaviors was only created on the day it was requested by the surveyor, rather than at the time the behaviors were first observed. Staff interviews confirmed that the resident was known to become angry quickly and had demonstrated both verbally and physically abusive behaviors, such as raising his voice, using profanity, and making demeaning statements. The psychiatric rehabilitation services coordinator acknowledged that the resident's quickness to anger and other behavioral issues were not care planned as required. Facility policy states that any observed behavior should be care planned immediately to ensure appropriate interventions can be implemented, but this was not followed in the resident's case.
Failure to Document COVID-19 Vaccination Status, Consent, and Education
Penalty
Summary
The facility failed to ensure proper documentation of COVID-19 vaccination status, consents, and education for four residents, despite having a policy requiring such documentation. Record reviews revealed that the immunization records for these residents contained no data regarding their COVID-19 vaccination status, consent, or education. Interviews with facility leadership and staff indicated a lack of consistent processes for tracking and auditing vaccination status, with leadership changes and a transition from paper to electronic records contributing to the deficiency. Staff reported that while the vaccine was offered and refusals were sometimes obtained verbally, there was no consistent documentation of consent or declination, and signatures were not always collected as required by policy. The residents involved had multiple complex medical diagnoses, including schizophrenia, bipolar disorder, asthma, hypertension, and depression. The facility's own policies required that all residents be offered the COVID-19 vaccine, that education be provided, and that documentation of acceptance, refusal, or exemption be maintained in the medical record. However, the investigation found that for the residents reviewed, there was no documentation of education, consent, or vaccination status, and staff were unclear on the current process for tracking and auditing this information.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the dining area, where a male resident with a history of Schizophrenia, Seizures, Depression, Scoliosis, and PTSD, and a BIMS score of 15/15, was physically assaulted by another male resident diagnosed with Schizoaffective Disorder, Bipolar Type, Diabetes 2, Anxiety, and Epilepsy, also with a BIMS score of 15/15. The altercation resulted in the first resident sustaining a bleeding lip, a bump to the right temporal area, and complaints of pain in his leg and arm. The assaulted resident reported feeling traumatized and fearing for his life during the incident. The report details that the altercation occurred when the first resident walked past the other resident's table, leading to the second resident knocking him to the floor and punching him multiple times in the face. Staff, including kitchen personnel, were present in the area but did not intervene during the incident. The assaulted resident's roommate intervened to stop the attack. The resident reported the incident to the DON, and nursing staff provided immediate care for his injuries, including treating his lip and applying ice to his head. The police were called but did not take action, and the resident was sent to the hospital but left before being evaluated due to a long wait. Documentation and interviews confirm that the facility was aware of the altercation and the injuries sustained. The resident was assessed by nursing staff, and the physician was notified. X-rays were ordered and returned negative for fractures. The incident was reported in facility documentation, and it was noted that the resident had no prior history of physical altercations. The facility's abuse prevention policy states that residents have the right to be free from abuse, neglect, and exploitation, but this right was not upheld in this instance.
Failure to Follow Elopement Policy During Resident Smoking Break
Penalty
Summary
The facility failed to consistently follow its elopement policy and procedure, resulting in a resident leaving the premises unsupervised during a scheduled smoking break. The resident, who was alert and oriented but forgetful, ambulatory with a steady gait, and had diagnoses including schizophrenia, major depressive disorder, and nicotine dependence, was able to elope despite staff being present to monitor the smoking area. The area was not enclosed, and staff were required to have a walkie talkie and immediately notify management if a resident attempted to leave. However, the staff member monitoring the smoking break did not immediately inform management or initiate the required emergency response when the resident eloped, instead relaying the information in passing to the receptionist after the fact. The delay in notification resulted in a lack of immediate response to the resident's elopement. The resident was eventually returned to the facility by police and was noted to be physically and verbally aggressive and non-directable upon return. Facility policy required staff to attempt to prevent residents from leaving, seek help from other staff, and immediately inform the charge nurse or DON if a resident left or attempted to leave. These steps were not followed, placing the resident's health and safety at risk.
Failure to Prevent and Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to prevent and protect residents from physical abuse, as evidenced by two separate physical altercations between two residents with intact cognition and histories of mental health disorders. Both residents had documented histories of aggressive and inappropriate behavior, including prior incidents of agitation and aggression. On the day of the incident, the first altercation occurred in the lobby, where one resident verbally provoked the other, leading to a physical fight in which punches were exchanged, resulting in a bloody nose for one resident. Multiple staff members, including an escort, activity aide, and maintenance director, were present and intervened to separate the residents. Despite the initial altercation, both residents were kept in proximity to each other on the same floor. Approximately an hour later, a second physical fight occurred in the same area, with both residents again exchanging blows, resulting in one being pinned to the ground and complaining of back pain. Staff had difficulty separating the residents during the second incident, and police and paramedics were called to the facility. Both residents were subsequently transferred to the hospital for evaluation and treatment. Interviews with staff revealed that there was a lack of specific training and procedures on how to handle abuse situations, and several staff members, including the maintenance director and DON, acknowledged that the second fight could have been prevented if the residents had been separated after the first incident. The facility's policies required the prevention of abuse, but staff actions did not prevent repeated physical altercations between the residents, resulting in physical harm.
Failure to Follow Abuse Prevention Policy and Staff Training Requirements
Penalty
Summary
The facility failed to follow its abuse prevention program policy and procedure in two key areas: timely review of criminal history background checks for new admissions and ensuring staff were educated and understood the abuse prevention program. Specifically, the facility did not check and review the criminal history background check within 24 hours of admission for one resident, despite the policy requiring this step. The resident's criminal history record was dated two days after admission, indicating the process was not completed as required. Additionally, two staff members, including an agency LPN and the Maintenance Director, were not educated or fully aware of the facility's abuse prevention program policy and procedure. The agency LPN, on her first day, was unaware of the abuse coordinator and had not received any abuse-related in-service or education. The Maintenance Director also reported not receiving specific training on how to handle abuse situations, which he believed contributed to the recurrence of a physical altercation between two residents. The deficiency was further evidenced by two physical altercations between residents with histories of mental health diagnoses, including schizophrenia and bipolar disorder. After the first altercation, both residents were kept in the same location, leading to a second fight. Multiple staff and residents confirmed that the second incident could have been prevented if the residents had been separated. The lack of staff training and failure to follow abuse prevention protocols contributed to the escalation and recurrence of resident-to-resident physical abuse.
Failure to Protect Resident from Staff-to-Resident Abuse and Timely Reporting
Penalty
Summary
A deficiency occurred when a resident with diagnoses including schizophrenia, insomnia, and ADHD, who was cognitively intact and required supervision with activities of daily living, was not protected from staff-to-resident abuse. The incident involved the Social Services Director (SSD) and was witnessed by another resident and an activity aide. According to witness statements, the SSD attempted to remove the resident from her office by shoving and pulling the chair out from under the resident, causing the resident to fall to the floor. The activity aide reported this action as abuse and stated that the situation escalated as a result of the SSD's actions. The resident became upset, broke the chair, and subsequently left the facility, leading to police involvement and a hospital transfer. The incident was not immediately reported to the Director of Nursing (DON) or the Administrator, both of whom stated they were unaware of the abuse allegation until informed by surveyors. The activity aide claimed to have reported the incident to the DON on the day it occurred, but the DON denied receiving any such report. The Administrator, who also serves as the abuse coordinator, was only made aware of the resident's behavioral outburst and not the alleged abuse by the SSD. Facility policy defines abuse as the willful infliction of injury or unreasonable confinement, and both the DON and Administrator acknowledged that pulling a chair from under a resident, causing a fall, constitutes abuse. The facility failed to ensure that the resident was protected from abuse and that allegations were promptly reported and investigated according to policy. The care plan for the resident specified that the resident should remain safe and free from mistreatment, and the facility's abuse prevention policy requires protection from abuse by anyone. The lack of timely reporting and investigation of the incident contributed to the deficiency identified by surveyors.
Inadequate Use of PPE and Linen Storage in Laundry Room
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy regarding the use of personal protective equipment (PPE) during the handling of soiled and clean linen. During an observation in the laundry room, it was noted that the staff member responsible for laundry, identified as V18, did not wear a gown while sorting and handling soiled laundry, only gloves. Additionally, there were no gowns available in the laundry area for use. The clean linen was stored uncovered under a metal table, and a large industrial fan was blowing air across both the dirty and clean areas, which were not physically separated, potentially leading to cross-contamination. The Housekeeping Director, identified as V19, confirmed that the staff should wear gowns and gloves when handling soiled laundry to prevent contamination. V19 acknowledged the absence of gowns in the laundry room and the lack of a physical barrier between the dirty and clean areas. The facility's policy on laundry services emphasizes the importance of using PPE, including gowns, gloves, and masks, during manual rinsing and sorting of soiled linen, and storing clean linen in a protected area. The failure to follow these procedures has the potential to affect all 77 residents in the facility.
Exposed Fluorescent Lights Pose Safety Risk
Penalty
Summary
The facility failed to provide a safe environment by not installing covers or guards on fluorescent tube lights located in over-the-head wall lights behind residents' beds. This deficiency was observed in the rooms of seven residents, affecting their safety and comfort. The exposed fluorescent tubes posed a risk of injury, as residents had to touch the bulbs to turn them on, and the tubes were covered in dust, indicating a lack of maintenance. Several residents, including those with intact cognition and those with cognitive impairments, reported using the over-the-head wall lights at night for reading or navigating their rooms without disturbing their roommates. The absence of covers or guards on these lights increased the risk of the tubes falling, breaking, or causing burns if touched when hot. The Maintenance Director acknowledged the safety concerns and confirmed that the lights should have protective covers or shields to prevent potential hazards. The facility's policy on maintenance and resident rights emphasizes the importance of maintaining a safe and operational environment, free from hazards. However, the lack of protective covers on the fluorescent lights in residents' rooms indicates a failure to adhere to these policies, compromising the safety and quality of life for the affected residents.
Failure to Provide Regular Podiatry Care for Resident
Penalty
Summary
The facility failed to adhere to its policy for nail care by not providing necessary toenail care for a resident, identified as R39, who was unable to perform this activity independently. Observations revealed that R39 had excessively long and curling toenails, with the large toenail appearing thick and scaly. Despite the resident's request for toenail trimming and the facility's policy that only a podiatrist should cut toenails, especially for diabetic residents, R39 had only been seen by the podiatrist once since admission. The resident expressed a desire for toenail care and denied ever refusing such services. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the podiatrist visits the facility monthly but alternates between floors, which may have contributed to the oversight. The facility's records did not document any refusals by R39 for podiatry services, contradicting the paper documents provided later, which indicated refusals on specific dates. R39's medical history includes conditions such as schizophrenia, type 2 diabetes, hypertension, and Alzheimer's disease, with a cognitive assessment indicating intact cognition. The facility's failure to provide regular podiatry care as per policy resulted in the deficiency noted in the report.
Failure to Communicate Specialist's Recommendation
Penalty
Summary
The facility failed to communicate a specialist's recommendation to the primary physician and follow through with the recommended treatment for a resident diagnosed with Schizoaffective Disorders, Schizophrenia, and Drug Induced Subacute Dyskinesia. The resident was receiving the antipsychotic medication Clozapine and was examined by a neurologist for Tardive Dyskinesia. The neurologist recommended speech therapy, but this recommendation was not communicated to the resident's primary physician, nor was a referral for speech therapy ordered as per the resident's physician orders from April 2024. The Director of Nursing stated that the facility's protocol requires nurses to communicate any specialist recommendations to the primary physician and document this communication in the resident's chart. However, there was no documentation indicating that the neurologist's recommendation for speech therapy was relayed to the primary physician. Consequently, the resident did not receive the recommended speech therapy, highlighting a lapse in the facility's communication and documentation processes.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, as evidenced by the case of a resident who was prescribed antibiotics without proper documentation or indication. The resident, identified as R71, was observed to be on Bactrim DS, an antibiotic, without any documented clinical rationale or prescriber notes to justify its use. The order for the antibiotic was handwritten by a pulmonologist, but there was no corresponding documentation in the electronic health record to support the prescription. Additionally, vital signs such as temperature and respiratory rate were not monitored after the antibiotic was prescribed, which is a requirement under the facility's antibiotic stewardship program. Interviews with various staff members, including registered nurses and the Director of Nursing, revealed a lack of clarity and understanding regarding the reason for the antibiotic prescription. The Director of Nursing mentioned that the resident had lung nodules and lung disease, and the antibiotic might have been ordered prophylactically, but there was no concrete documentation to support this. The Infection Verification Form indicated that the criteria for pneumonia were not met, yet the resident was still on antibiotics. The staff acknowledged that vital signs should have been monitored and documented, but this was not done. Further investigation into the pulmonologist's notes revealed a suspicion of active rheumatoid lung and a plan to rule out methotrexate toxicity, but it was still unclear why the antibiotic was prescribed. The resident himself was unaware of the reason for the antibiotic treatment. The facility's antibiotic stewardship program requires prescribers to document the dose, duration, and indication for all antibiotic prescriptions, and to monitor clinical assessments and vital signs, which were not followed in this case.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet per bed for five resident rooms out of a total of 68 rooms. During an observation and interview on June 24, 2024, the Administrator acknowledged that five rooms did not meet the required square footage. On June 25, 2024, a surveyor, accompanied by the Maintenance Director, inspected these rooms and found that four were unoccupied, while one room was occupied by three residents who reported no concerns about the room size. The facility presented documentation indicating that these rooms had been granted a waiver by the Illinois Department of Public Health, allowing them to operate with less than the required square footage, as long as it did not affect resident health, safety, or welfare.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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 Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center Home Hispanic Elderly | 0.8 mi | ★★★★★ | 16 | 0 |
| Avantara Lincoln Park | 1.5 mi | ★★★★★ | 9 | 0 |
| Little Sisters Of The Poor | 1.5 mi | ★★★★★ | 0 | 0 |
| Pavilion Of Logan Square, The | 1.6 mi | ★★★★★ | 14 | 0 |
| Landmark Of Lincoln Park Rehabilitation And Nursin | 2.4 mi | ★★★★★ | 4 | 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.