The facility's Psychiatric Rehabilitation Services Coordinator admitted she "messed up" when federal inspectors requested the resident's behavior care plan on August 15. The resident, identified as R8, had been living at the facility since July 9 with diagnoses including schizoaffective disorder, depression, and mild intellectual disabilities.
"Any moment a behavior is exhibited by the resident, that behavior should be care planned so when the behavior is repeated, an intervention can be implemented to deescalate the behavior," the coordinator told inspectors.
The door-kicking incident occurred on July 28. V16, a Psychiatric Rehabilitation Services Assistant, witnessed R8 become upset during paperwork when she asked him to wait while she finished writing something he wanted documented.
Staff described a pattern of escalating behaviors with no formal intervention plan. V13, an escort, told inspectors R8 "gets angry really quickly" and she had seen him become upset when staff denied his request for food. During that incident, R8 raised his voice and repeatedly mumbled "Why?"
The facility only created behavior care plans on August 15 — the same day inspectors requested them and nearly three weeks after the door-kicking incident. The hastily developed plans documented "socially inappropriate and maladaptive behavior" and noted R8's history of "dysfunctional behavior, mental illness diagnoses, anger, agitated depression" and "restless/agitated behavior."
A second care plan addressed what staff described as "verbally physically abusive behavior." The documentation listed R8's tendency to "push, shove, scratch, hit, slap, kick, grab or otherwise harm another person" and noted his "use of profanity, demeaning statements, verbal threats and yelling at others."
The coordinator acknowledged that R8's quick temper — which she described as feeling "like he is having tantrums" — should have been addressed in care planning from the beginning. "His being quick to anger is not care planned. And it should have been 100% care planned," she told inspectors.
Federal regulations require nursing homes to develop comprehensive, person-centered care plans that address residents' physical, mental, and psychosocial needs. The plans must include measurable objectives and describe services needed to maintain residents' highest practicable well-being.
Care plans must also be updated when residents' conditions change or new behaviors emerge. The facility's own policy states that assessments are ongoing and care plans should be revised as information about residents changes.
R8's case demonstrates how the absence of proper behavior planning can leave staff unprepared to handle psychiatric emergencies. Without established interventions, episodes of agitation, verbal threats, and physical acting-out continue unchecked.
The coordinator's admission that she realized the oversight only when inspectors asked for documentation suggests the facility's care planning process lacks systematic review. Staff witnessed concerning behaviors for weeks but failed to translate those observations into formal care strategies.
The facility's failure affected one resident in the sample of 15 reviewed during the August 25 complaint investigation. Inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
The delayed response to R8's behavioral needs violated federal requirements for comprehensive care planning. Staff described a resident whose mental health conditions manifested in increasingly disruptive ways, yet the facility provided no structured approach to address his psychiatric symptoms or prevent escalation.
Winston Manor's belated care plans acknowledged R8's "ineffective coping mechanisms" and "poor verbal skills" that contributed to inappropriate expressions of frustration. But these insights came only after inspectors highlighted the regulatory failure, not through the facility's own clinical assessment process.
The case illustrates broader concerns about psychiatric care in nursing facilities, where residents with serious mental illness may receive inadequate behavioral health services. R8's combination of schizoaffective disorder, depression, and intellectual disabilities required specialized interventions that the facility failed to develop or implement.
Without proper behavior plans, staff lacked guidance on recognizing triggers, implementing de-escalation techniques, or preventing situations that might provoke aggressive responses. The door-kicking incident and food-related outburst suggest R8's frustrations could have been anticipated and managed through appropriate psychiatric care planning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winston Manor Cnv & Nursing from 2025-08-25 including all violations, facility responses, and corrective action plans.