Winston Manor: Abuse Reporting Failures - IL
The resident, identified in inspection records as R1, told police when they arrived that R2 had attacked her. That was, in R1's own words, "the truth." R2 was sent to the hospital for a psychiatric evaluation after refusing medication offered to calm her down.
None of that information made it into the facility's internal account of what happened.
A witness statement filed under the name of a staff member identified as V5 described what occurred as a "verbal disagreement" that staff quickly separated. The statement said nothing about thrown objects, nothing about R1 being struck, nothing about a 911 call. When inspectors read that statement aloud to V5 during the survey on December 31, her response was immediate. "I never wrote or gave anyone my statement," she said. "That statement is not the truth. No one asked me what happened or what I witnessed."
Someone had written it anyway, and filed it under her name.
The Director of Nursing, identified as V2, told inspectors on December 30 that she had received a phone call from the floor nurse on the morning of December 26 describing a verbal argument and R2 throwing items. She said she spoke with R1 later that same day. R1 did not tell her she had been hit. The Director of Nursing did not ask. "I did not ask R1 if she was hit by R2 or any items hit R1," she told inspectors.
That was the end of her inquiry.
The administrator, identified as V1, gave inspectors a similar account. He knew about the argument on December 26. He knew R2 had been sent to the hospital. He knew R1 had called 911. He said he did not know what R1 told the police when she called, and he said he did not know why she called. He had not obtained a copy of the police report. He spoke with R1 on December 26, and R1 did not tell him she had been struck. He did not ask.
"I was not aware of the severity of the argument until 12/29/25 during morning meeting," the administrator told inspectors. Three days after R1 had called the police to report that her roommate attacked her, the administrator said he learned for the first time that the incident had been serious. He said he then tried to report it to the Illinois Department of Public Health.
By that point, the facility's own abuse policy required reporting within two hours of an allegation.
The inspection was classified as a complaint survey, completed December 31, 2025. The deficiency was cited at the "Actual Harm" level, meaning inspectors determined a resident had been genuinely injured or endangered, not merely placed at theoretical risk. The citation falls under F0600, which covers a resident's right to be free from abuse and requires that facilities investigate and report allegations immediately.
What the record shows is a facility that had, within hours of the incident, every piece of information it needed to trigger that process. The floor nurse told the Director of Nursing that R2 had been throwing items. R1 called 911 and told officers her roommate attacked her. R2 was sent out for a psychiatric evaluation specifically because of her behavior during and after the confrontation. And yet the internal account that was prepared, the written statement filed under V5's name, reduced all of it to a verbal disagreement that staff calmly resolved.
V5 says she never wrote that statement. She says no one even asked her what she saw.
The facility's abuse policy, dated September 2025 and included in the inspection record, defines abuse as the willful infliction of injury and describes immediate reporting as a requirement, with "immediate" specified as within two hours of an allegation. The policy states that all reports of resident abuse are reported to local, state, and federal agencies and thoroughly investigated by facility management, and that findings of all investigations are documented and reported.
The investigation that actually took place consisted of managers asking R1 whether she had been struck, R1 not volunteering that information, and managers not following up. No one interviewed V5, the witness whose name later appeared on a statement she says she never gave. The administrator did not request the police report from a call that R1 placed from inside his facility.
R2 was eventually returned to the facility and moved to a different room.
R1 remained at Winston Manor. The inspection record does not describe what, if any, follow-up she received after the December 26 incident, or whether anyone at the facility subsequently asked her, directly, what had happened to her that morning.
She had already answered that question once, for the police, on the day it happened. She told them her roommate attacked her, and she told them it was the truth. The facility's written record said something different, under the name of a staff member who says she was never consulted.
That is where the inspection record ends.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winston Manor Cnv & Nursing from 2025-12-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 20, 2026 · Our methodology
WINSTON MANOR CNV & NURSING in CHICAGO, IL was cited for abuse-related violations during a health inspection on December 31, 2025.
The resident, identified in inspection records as R1, told police when they arrived that R2 had attacked her.
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.