Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Level of Harm - Minimal harm
or potential for actual harm Based on observation, interview, and record review the facility failed to provide a safe environment by not
providing covers or guards for florescent tube lights located in over the head wall lights behind resident's
Residents Affected - Some bed. These failures affected seven residents (R8, R22, R36, R39, R46, R55, R70) when reviewed for
environment in the sample of 21 residents.
Findings include:
R36 has diagnoses of but not limited to Chronic Obstructive Pulmonary Disease, Schizophrenia, Seizures,
Hyperlipidemia, Hypertension, Diverticulitis, Obesity, Gastro-Esophageal Reflux Disease. R36's BIMS
dated 04/30/24 documents score of 15/15 indicating intact cognition.
On 06/24/24 at 10:42 AM, observed R36's over the head wall light with exposed florescent tube light. The
florescent light tube had no cover or guard over it. R36 stated R36 uses the over the wall light behind R36's
bed at night when R36 reads because the main light in the ceiling is too bright and R36 does not want to
keep R36's roommates up. R36 stated that light behind R36's bed has never had a plastic cover or guard
covering the light bulb. Observed R36 pull string to turn on the over the head wall light. The light did not turn
on. R36 said, I have to touch the light bulb to get it to turn on. See? Then, observed R36 touch the
florescent light tube causing the light to turn on.
R22 has diagnoses of but not limited to Type 2 Diabetes Mellitus, Long Term Use of Insulin, Asthma,
Hyperlipidemia, Schizophrenia, Hypertension, Hyperlipidemia, Osteoarthritis, Unspecified Dementia. R22's
BIMS dated 05/13/24 documents score of 10/15 moderately impaired cognition.
On 06/24/24 at 10:58 AM, observed R22's over the head wall light with exposed florescent tube light. The
florescent tube light was not covered with a guard or cover. The florescent light tube was covered in a layer
of dust.
R70 has diagnoses of but not limited to Hypertensive Heart Disease without Heart Failure, Hyperlipidemia,
Non-ST Elevation Myocardial Infarction, Obesity, Anemia. R70 BIMS dated 05/02/24 documents score of
15/15 indicating intact cognition.
On 06/24/24 at 11:08 AM, observed R70's over the head wall light with exposed florescent tube light. The
florescent light tube did not have a cover or guard covering it.
R55 has diagnoses of but not limited to Chronic Obstructive Pulmonary Disease, Violent Behavior, Alcohol
Abuse with Intoxication, Asthma, Chronic Embolism and Thrombosis of Unspecified Vein. R55 BIMS dated
04/12/24 documents score of 13/15 indicating intact cognition.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE
REPRESENTATIVE'S SIGNATURE
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 1 of 7
14E169
Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 On 06/24/24 at 11:10 AM, observed R55's over the head wall light with exposed florescent tube light with
no cover or guard.
Level of Harm - Minimal harm
or potential for actual harm R39 has diagnoses of but not limited to Schizophrenia, Type 2 Diabetes Mellitus without Complications,
Hypertension, Bipolar Disorder Current Episode Mixed Severe with Psychotic Features, Delusional
Residents Affected - Some Disorders, Generalized Anxiety Disorder, Alzheimer's Disease, Unspecified Psychosis, Age Related
Nuclear Cataract Bilateral. R39's BIMS dated 04/17/24 documents score of 14/15 indicating intact
cognition.
On 06/24/24 at 11:14 AM, observed R39's over the head wall light with exposed florescent tube light. The
florescent light tube was not covered. R39 stated, I use that light at night when its dark in my room so I can
see where I'm going if I get up to go to the bathroom.
R46 has diagnoses of but not limited to Asthma, Seizures, Schizoaffective Disorders, Major Depressive
Disorder, Hypertension, Gastro-Esophageal Reflux Disease. R46's BIMS dated 04/19/24 documents score
of 05/15 indicating severely impaired cognition.
On 06/24/24 at 11:27 AM, observed R46's over the head wall light with exposed florescent tube light with
no cover or guard. R46 said, I use my light at night when its dark in the room so I can color and write stuff
without bothering my roommates. R46 stated there should be a cover on the light so it doesn't break all
over the floor or near my (R46) head.
R8 has diagnoses of but not limited to Type 2 Diabetes Mellitus without Complications, Long Term Use of
Insulin, Atrial Fibrillation, Schizophrenia, Hypertension, Seizures, Hyperlipidemia, Extrapyramidal and
Movement Disorders. R8's Brief Mental Status Interview (BIMS) dated 05/09/24 documents score of 13/15
indicating intact cognition.
On 06/24/24 at 11:38 AM, observed R8's over the head wall light with exposed florescent tube light with no
guard/shield or cover. R8 stated R8 uses that light at night so R8 can see in R8's room. R8 stated there is
no cover over it and there should be one in case it breaks because that light is made of glass.
On 06/24/24 at 2:56 PM, V5 (Maintenance Director) stated V5 is responsible for making sure things are in
working order in the resident rooms including the lights. V5 stated the residents use the over the head wall
light at night when reading or walking around the room so they do not wake up their roommate. V5 stated
there should be plastic covers covering the florescent light tubes or shields/guards covering the individual
florescent light tubes because the light tubes could fall, break, and hit someone in the head. V5 also stated
residents could burn their hands if they were to touch the florescent tube lights when they were hot from
being turned on. Surveyor toured R36 and R8's room with V5 who observed exposed florescent light tubes
and V5 stated those lights should have covers or shields/guards over them for potential safety concerns
and to keep the residents safe.
Facility provided document titled, Maintenance Requests and Repairs dated 04/10/17 which documents in
part, the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a
safe and operational manner at all times. Maintaining the building in good repair and free from hazards. Any
maintenance concern identified that affects resident safety will be communicated to the maintenance
department immediately.
Facility provided document titled Policy on Resident Rights, Respect and Dignity dated January 2016
(continued on next page)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 2 of 7
14E169
Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 which documents in part, a facility must treat each resident with respect and dignity and care for each
resident in a manner and in an environment that promotes maintenance or enhancement of his or her
Level of Harm - Minimal harm quality of life.
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 3 of 7
14E169
Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm Based on interview and record review, the facility failed to communicate to the primary physician and follow
or potential for actual harm Neurology recommendation for 1 (R7) resident out of the final sample of 21.
Residents Affected - Few Findings Include:
R7's electronic health records show R7 has diagnoses not limited to Schizoaffective Disorders,
Schizophrenia, and Drug Induced Subacute Dyskinesia. R7's physician orders show R7 is receiving
antipsychotic medication Clozapine. R7's Neurology Clinic's AFTER VISIT SUMMARY dated 4/9/24 shows
R7 was examined by V24 (Medical Doctor) for Tardive Dyskinesia and recommended speech therapy for
R7. R7's physician orders from April 2024 does not show a referral for Speech Therapy was ordered. R7's
progress notes dated 4/9/24 at 1:06 PM reads, resident came back without follow up apt. No documentation
that shows V24's recommendation was communicated and followed-up with V25 (Primary Physician).
On 6/24/24 at 12:30 PM, V2 (Director of Nursing) stated that after the resident comes back from a specialist
doctor's appointment, the expectation is for the nurse to read the after visit summary to the resident's
primary physician and carry out the order. V2 stated that whenever there's a recommendation from the
specialist, it needs to be communicated with the resident's primary physician so they are on the same
page. V2 further stated that nurses are supposed to document in the resident's chart once they relay the
recommendations to the primary physician. V2 stated that if it's not documented, it means it's not done. V2
stated that R7 takes psychotropic medications and has tardive dyskinesia and extrapyramidal symptoms
(EPS). V2 stated that R7 is being seen by a Neurology specialist related to these symptoms. V2 stated that
R7 has not been seen by the Speech Therapy. V2 stated that the Speech Therapy recommendation from
the 4/9/24 appointment was missed and R7 was not referred to a Speech Therapy.
The facility's policy titled; Physician's Orders dated 1/1/20 reads in part:
All resident medications, and treatments must be ordered by a licensed physician or Nurse Practitioner.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 4 of 7
14E169
Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm Based on observation, interview, and record review the facility failed to follow facility policy regarding
or potential for actual harm wearing personal protective equipment (PPE) during manual handling of linen during sorting/rinsing and
storing clean linen in a protected area. This failure has the potential to affect all 77 residents residing in the
Residents Affected - Many facility based on daily census dated 06/24/24.
Findings include:
On 06/25/24 at 11:35 AM, met with V18 (Housekeeping/Laundry) in the laundry room located on the 1st
floor. V18 stated V18 has been working at the facility for 18 years, and usually works the day shift by
himself. Observed large industrial fan blowing air at full blast aimed toward the dirty/clean work areas. There
was no physical barrier separating the dirty/clean work areas. A box of gloves and masks observed by the
door. No gowns or disposable gowns observed in the laundry area. A load of laundry was washing in the
industrial clothing washer. Observed cleaned linen items folded and stored under a long metal table which
were not covered with any type of protective covering. Surveyor could see folded/uncovered linen items
blowing from the air flow coming from the large industrial fan. V18 stated V18 puts on gloves before V18
handles the dirty laundry to sort. V18 stated, I don't wear a gown, only gloves. Surveyor asked if there were
any disposable gowns available for V18 to put on. V18 looked around the laundry room and stated, no,
there are not any gowns in here. V18 stated after handling the soiled laundry V18 washes V18's hands,
puts on a new set of gloves and then takes the cleaned items out of the washer and puts them into the
dryer. V18 stated V18 does not wear a gown, only gloves when handling the cleaned items. V18 stated after
the cleaned laundry comes out of the dryer, V18 brings them to the long metal table and folds the items and
stores the cleaned/folded items underneath the metal table on the shelf or on a cart. V18 stated the bed
pads, gowns, fitted sheets and towels get stored underneath the folding table and the flat sheets, coverlets
and blankets get stored over there on the cart. V18 stated the items under the folding table are not covered
with anything. V19 asked surveyor, should they be covered? Surveyor observed folded uncovered gowns
being moved from the air circulating from the large industrial fan nearby.
On 06/25/24 at 11:50 AM, V19 (Housekeeping Director) stated V19 has been working at the facility for six
years. V19 stated the laundry staff should wear gown and gloves when handling soiled laundry because the
items are dirty. V19 stated sometimes the soiled items are covered in pee and poop and wearing a gown
will prevent the pee and poop from getting on the employees clothing. V19 stated it is an infection control
concern because cross contamination can occur when the staff goes from handling soiled laundry to clean
laundry and that is why the staff needs to wear a gown and gloves. Surveyor asked V19 where the gowns
are for the staff to use. Observed V19 look around and stated there are no gowns in here right now. V19
stated, I forgot to put them in here. That is on me. V19 stated it is important to separate the dirty and clean
laundry and stated this is the clean side of the laundry room, and this is the dirty side pointing to a very
faded line on the floor of the laundry room to indicate the separation line. There is no physical barrier
separating the dirty/clean work areas and the industrial fan was angled toward the dirty side and partially
toward the clean side of the painted line. V19 acknowledge that the fan is blowing toward the dirty and
clean area. V19 stated the cleaned/folded items should be covered with something to prevent cross
contamination with the fan blowing toward the dirty side of the room.
Facility provide policy titled, Laundry Services dated 4/2021 which documents in part,
1.)
(continued on next page)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 5 of 7
14E169
Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Soiled linen has shown to be a source of large number of microorganisms. The risk of actual disease
transmission is negligible if handled, transported, and laundered in a manner that minimizes exposure or
Level of Harm - Minimal harm contamination and avoids transfer of microorganisms.
or potential for actual harm
2.)
Residents Affected - Many
Techniques to minimize potential nosocomial and occupational risks associated with soiled linen handling
include Wear personal protective equipment to include gown, gloves, and mask during manual rinsing and
sorting.
3.)
Efforts to reduce risk of transmission or exposure of infection to laundry staff primarily focus on protective
barriers.
4.)
Store clean linen in a protected area until distribution for resident care.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 6 of 7
14E169
Department of Health & Human Services Printed: 05/23/2026
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
14E169 B. Wing 06/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Winston Manor Cnv & Nursing 2155 West Pierce
Chicago, IL 60622
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Level of Harm - Potential for
minimal harm Based on observation, interview and record review, the facility failed to provide the required 80 square feet
per bed for 5 resident rooms out of 68 resident rooms in the facility.
Residents Affected - Some
The findings include:
On 6/24/24 at 9:53 AM V1 (Administrator) stated there are 5 rooms with less than the required square
footage.
On 6/25/24 at 10AM Surveyor rounded 5 rooms with V5 (Maintenance Director). V5 stated he started
working in the facility on January 2, 2024. Observed 4 rooms were not occupied. R22, R23 and R46
occupied 1 room and stated no concerns with room square footage or size of room. They said they can
move around the room with no concerns.
Facility provided document titled List of rooms under room waiver documented in part: 4 resident rooms
with square footage of 15 x 17 and 1 room with square footage 13 x 18.
Facility document presented by V1, titled Illinois Department of Public Health Waiver Status Report and
dated 06/20/96, documents in part, the facility has 5 rooms that do not have a minimum of 10 feet between
walls or a wall and any built-in furniture, and the facility will ensure this situation does not affect resident
health, safety, or welfare.
Facility provided document titled Illinois Department of Public Health dated 9/13/2021 documented in part:
Approved request for a waiver.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete Page 7 of 7
14E169