Winston Manor CNV: Immediate Jeopardy Elopement Failures - IL
The inspection, triggered by a complaint and conducted August 25, 2025, found conditions serious enough to warrant an immediate jeopardy citation, the most severe finding federal inspectors can issue, reserved for situations where a facility's failures have placed residents in serious danger of harm or death. The facility serves 123 residents.
The three departures happened within a span of days. Resident 6 left without authorization on August 9. Resident 5 left without authorization on August 11. Resident 7 eloped, the clinical term for an unplanned, undetected departure by a resident who cannot safely leave on their own, also on August 11. The Illinois Department of Public Health was not notified of any of these incidents until August 21, ten days after the last two occurred.
Ten days.
What inspectors found when they looked at how the facility tracked residents coming and going was a system that, in practice, was not working. There was no consistently updated list at the front desk or nursing stations showing which residents were permitted to leave on their own and which were not. There were no standing physician orders for residents who wanted to go out on pass. Staff at the front desk had no defined procedure for monitoring when residents who had left were expected to return, no protocol for what to do when someone didn't come back, and no clear trigger for when a missing person investigation should begin.
The facility's own policies said something different. Its outside pass policy stated that residents could not be considered for community pass privileges without a physician's order. Its missing resident policy stated that staff should account for all at-risk residents at the beginning of each shift, during medication passes, and at each meal. Neither policy was being followed in any documented, consistent way before the three departures happened.
A smoking evaluation policy existed as well. The facility was supposed to assess each resident's ability to smoke safely, with or without supervision, and staff were supposed to consult with the attending physician and director of nursing to determine whether safety restrictions needed to be placed on a resident's smoking privileges. Inspectors noted this policy in connection with the elopement findings, an indication that movement during smoking breaks was part of how residents were getting out.
By August 14, three days after the last two unauthorized departures, the director of nursing had initiated a head count of the entire facility and documented it. That was the first formal accounting of where every resident was.
The remediation the facility scrambled to put in place in the days that followed tells its own story about how little had existed before. Updated lists of which residents could and could not leave were printed and placed at the reception desk and each nursing station, starting August 15. Pass orders were initiated for all residents by the director of nursing, something that should have been in place for every resident already. Front desk staff were trained, for the first time in any documented sense, on what to do when a resident on pass didn't come back: search the facility, notify the administrator and director of nursing, contact the resident's family, call local hospitals.
On August 18, two-hour rounding by nurses and certified nursing assistants was initiated to ensure residents were being accounted for throughout the day. Also on August 18, head counts during smoking breaks began, with designated staff signing residents in and out of the facility each time a smoke break occurred.
Elopement binders, containing photographs of residents identified as at risk for wandering or exit-seeking, were assembled and placed at every nursing station, in the kitchen, at the front desk, and in department head offices. The Social Services Director developed care plans for all residents identified with wandering behavior or elopement risk. These binders and care plans were initiated on August 15.
All of it initiated on August 15. Four days after two residents walked out on the same day.
Inspectors confirmed through record review and staff interviews on August 19 and 20 that these steps had been taken, and the immediate jeopardy designation was lifted. But the deficiency was not cleared. Inspectors left it at a level two finding, meaning the violation remained on the record, because not enough time had passed to evaluate whether the new training and procedures were actually working or whether staff had genuinely absorbed what they were supposed to do differently.
That distinction matters. A facility can write a policy in an afternoon. Whether the night shift nurse at 2 a.m. knows which resident is restricted from leaving, and acts on that knowledge, is a different question entirely.
The inspection report does not describe what happened to Resident 6, Resident 5, or Resident 7 after they left. It does not say whether they were found quickly or after hours. It does not say whether any of them were injured, became disoriented, or wandered into traffic or weather. It does not say whether family members were notified while the residents were still missing, or only after they were located, or only after IDPH was finally called ten days later.
What the report does say is that Resident 7's departure is described as an elopement, the word inspectors use when a resident is not capable of making a safe, informed decision to leave. The other two are described as unauthorized leaves, a distinction that suggests those residents may have had more awareness of what they were doing but lacked permission under the facility's own policies. All three left a 123-bed facility that had no working front desk protocol for tracking when anyone was expected back.
Nursing homes are required to know where their residents are. That obligation is not complicated in concept. In practice, at Winston Manor CNV & Nursing in August 2025, it was not being met. Three people walked out in three days, and it took the facility ten days to tell state regulators it had happened at all.
The elopement binders are now in the kitchen. The head counts happen at shift change. The lists at the nursing stations are updated. Whether the staff who work overnight, on weekends, at the end of a double shift, treat those binders and those lists as something real, something connected to an actual person who might walk out a door and not find their way back, is what no policy document can guarantee.
Resident 7 left on August 11. The inspection report does not say where they went, or how long they were gone.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 6, 2026 · Our methodology
WINSTON MANOR CNV & NURSING in CHICAGO, IL was cited for immediate jeopardy violations during a health inspection on August 25, 2025.
The facility serves 123 residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.