Winston Manor CNV & Nursing

In the surveyor’s words

From the most serious findings on record at Winston Manor CNV & Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 25, 2025

  Based upon interviews and record review the facility failed to: conduct head counts (every two hours); failed to provide supervision for one resident (R7) in the sample; failed to follow Doctor's pass order for one resident (R5); and failed to implement the elopement and pass policies for three residents in a sample of 15 (R5, R6 and R7). These failures resulted in an immediate jeopardy and has the potential to affect 123 residents that reside in the facility.An immediate jeopardy began on 8/9/25 at 9:00 am, when R6 left the facility unauthorized and continued with subsequent failures that led to R5 and R7 also being away unauthorized.On 8/14/25 at 3: 47.pm, V1 (Administrator) and V20 (Regional Consultant) were notified of the Immediate Jeopardy and the IJ template was presented.On 8/19/25… […]

• Actual harm, isolatedF689Jan 8, 2026

  Based on interviews and record review, the facility failed to ensure that the residents' bathroom floor was dry and free of a liquid substance. This failure has resulted in one resident (R1) slipping on the bathroom floor and sustaining fractures to her ankle. Findings include:R1 is [AGE] year-old with diagnoses including but not limited to: morbid obesity, epilepsy, vitamin D deficiency, type 2 diabetes mellitus and hypertension.R1 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.On 1/5/26 at 2:43 PM, R1 stated the following, I was discharged from the hospital on October 9, 2025, and am now at a different nursing facility. My ankle was broken in three places while in the last nursing home (named facility). […]

• Actual harm, isolatedF600Dec 31, 2025

  Based on interview and record review the facility failed to prevent resident to resident verbal and physical abuse for one [R1] out of three residents reviewed for abuse. This resulted in R1 sustaining physical pain and mental anguish.Findings Include: R1's clinical record indicates the following in part: R1's medical diagnoses of post -traumatic stress disorder, chronic obstructive pulmonary disease, anxiety disorder, schizoaffective disorder, and overactive bladder.R2's clinical record indicates the following in part: Medical diagnoses: Schizoaffective disorder and major depressive disorder.R2's progress notes in part:V6 [Licensed Practical Nurse] note:12/26/2025 3:46 AM Note Text: This writer heard loud yelling in R2's room around 1:45 AM. […]

• Actual harm, isolatedF600May 15, 2025

  Based on interview and document review the facility failed assure the resident right to be free of physical abuse in 1 of 3 (R1) residents in a total sample of 8 residents. This failure resulted in R1 having bleeding lips, bump to right temporal area and feelings of fearing for his life. Findings include: The following incident took place on 4/28/25, around dinner time in the facility dining area. R1 is a [AGE] year-old male with diagnoses including Schizophrenia, Seizures, Depression, Scoliosis and Post-Traumatic Stress Disorder. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview of Mental Status) score of 15/15. R1 is care planned for including alteration in mental health function due to Schizophrenia and Depression. […]

• Actual harm, isolatedF600Apr 21, 2025

  Based on interview and record review, the facility failed to prevent and protect residents from physical abuse. This failure affected 2 (R1 and R2) out of 7 residents reviewed for abuse. R1 and R2 had a brawling incident on 3/28/25 that resulted in R2 having a nosebleed. The findings include: R1's admission record showed admitted on 2/24/2025 with diagnoses not limited to Schizophrenia, Insomnia, Anorexia, Attention-deficit hyperactivity disorder, predominantly inattentive type. MDS (Minimum Data Set, dated dated dated [DATE] showed R1's cognition was intact. R2's admission record showed admitted on 1/13/2025 with diagnoses not limited to Schizophrenia, Bipolar disorder, Depression, Essential (primary) hypertension, Insomnia. MDS dated [DATE] showed R2's cognition was intact. […]