Winston Manor Nursing: Care Plan Failures - Chicago, IL
The resident, identified in inspection records only as R8, was admitted to the facility on July 9, 2025. Within weeks, staff were witnessing outbursts, a kicked door, repeated demands for food met with refusals that sent him into escalating anger. Nobody had written down what to do about any of it.
The behavior care plan was created on August 15, 2025, the same day the inspector requested it.
An escort worker at the facility, identified in the report as V13, told the inspector that R8 "gets angry really quickly" and that she had watched him become upset when staff refused him food. He raised his voice and mumbled "Why?" over and over. A psychiatric rehabilitation services assistant, V16, described a separate incident from July 28, nearly three weeks into R8's stay, when she asked him to wait while she finished paperwork. He kicked the social services office door.
That July 28 incident had never been care planned.
V16 told the inspector that the behavior "should have been care planned on the day the behavior was observed to ensure who sees the behavior of kicking knows what to do." That is not a regulatory abstraction. It means the next staff member who watched R8 kick a door, or raise his voice, or go rigid with frustration because no one could understand what he needed, had nothing to guide them. No intervention. No de-escalation approach. No documented recognition that this man, who had poor verbal skills and a history of mental illness, was communicating something when he acted out.
The facility's own psychiatric rehabilitation services coordinator, V3, told the inspector she "realized she messed up because she did not put any behavior care plan for him." She said R8 was "quick to anger" and that it felt like he was "having tantrums." Then she said something that made the gap plain: "His being quick to anger is not care planned. And it should have been 100% care planned."
That admission came on August 16, the day after the plan had been hastily assembled.
R8's diagnoses, schizoaffective disorder, depression, and mild intellectual disabilities, were documented in his admission record from the start. The care plan that eventually appeared on August 15 listed a range of behaviors: pushing, shoving, scratching, hitting, slapping, kicking, grabbing. It noted poor verbal skills, ineffective coping mechanisms, and verbal threats. It described a man being "challenged by mental illness." All of that was true from the moment he arrived. None of it had been formally addressed for more than five weeks.
The inspection, conducted as a complaint survey, identified the failure as affecting one resident out of 15 reviewed. The level of harm was classified as minimal harm or potential for actual harm. That classification reflects the regulatory floor, not the daily reality of a man with significant psychiatric diagnoses living in a facility where no one had written down how to help him when he fell apart.
Care planning for behavioral and psychosocial needs exists precisely because residents like R8 depend on a rotating cast of staff, aides, nurses, escorts, rehabilitation workers, none of whom can be expected to carry institutional knowledge in their heads. When a new aide encounters R8 asking for food and being told no, and he begins repeating "Why?" louder and louder, a care plan is the difference between a staff member who knows what to try and one who doesn't.
Winston Manor had neither for 37 days.
What V13, the escort, described watching, a man asking for food, being refused, and cycling into distress, happened before anyone had documented a single intervention. Whether anyone used that moment to help him calm down, or whether it simply ended the way unguided encounters with an agitated, mentally ill resident often end, the inspection report does not say.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
WINSTON MANOR CNV & NURSING in CHICAGO, IL was cited for violations during a health inspection on August 25, 2025.
The resident, identified in inspection records only as R8, was admitted to the facility on July 9, 2025.
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.