Winston Manor Convalescent and Nursing

Facility I.D. Number: 0035782
2155 W. Pierce Ave.
Chicago, IL 60622

Date of Survey: 01/22/04

Complaint Investigation

“A” violation(s):

The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.

All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.


This REQUIREMENT is not met as evidence by:

Based on direct observation, record review and interview, the facility failed to: 1) provide the necessary services to ensure that one resident (R3) was free from physical harm; and 2) investigate the circumstances of R3’s injury to ensure that other residents are not at risk.

R3 was hospitalized for more than one month in the Burn Unit of an acute care hospital and currently remains hospitalized on a skilled unit in another acute care hospital.

Findings include:

  1. According to the incident report of 12/16/03 (for the incident dated 12/12/03), R3 was sent to the hospital via ambulance with “reddened areas on his anterior chest, abdomen, neck and upper arms.” On interview on 1/16/04, E4 (CNA) who was assigned to R3 on 12/12/03, stated that during rounds she observed the resident standing in the bathroom, attempting to remove his shirt. She described the shirt as a sleeveless undershirt and stated that there were burned marks evident on the shirt.
  2. The “Patient Care Report” from the ambulance service documented 2nd degree burns to the chest, neck, both arms, right ear and abdomen as the reason for ambulance transport. In the comments section, it was documented that R3 had, “2nd degree burns with blistering and redness to chest, neck, abdomen, both arms and hands, right ear, and the right side of his head.” This document also stated, “Per staff, patient was smoking a cigarette in the restroom that ignited his shirt.”
  3. Review of clinical record for R3 indicated that the resident was re-routed to a closer hospital for clinical treatment.
  4. On 01/06/04, it was determined by phone that R3 was a patient in the burn unit ICU and had just undergone another surgery. The nurse clarified the extent of his injuries as 3rd degree burns to his neck, chest, arms and hands.
  5. Review of the clinical record for R3 at the hospital on 01/20/04 confirmed that the resident had sustained 2nd and 3rd degree burns to 26% of his body.
  6. On direct observation on 01/20/04, R3 was noted to be in bed. He had burns in various stages of healing on his chest, abdomen, arms, hands, neck, right ear and right side of his face. He also was noted to have healing areas on both thighs where skin had been taken for grafting.
  7. Review of the facility incident report was limited to a brief statement of redness. There was no investigation information provided. On interview, E1, the Administrator, confirmed that no investigation was conducted. The facility was unable to provide any information regarding how this resident received 2nd and 3rd degree burns. On interview of the two CNAs (E3, E4) who were working on the unit when the incident occurred, they both stated that they had no idea what happened. There was no attempt by the facility to determine the cause of the injury and there was no attempt to initiate measures to ensure that this does not happen to any other residents. Facility failed to follow and implement a policy to investigate this incident.