Inspection Reports for
Westminster Village Al
2025 E Lincoln St, Bloomington, IL, 61701
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
125% occupied
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 2, 2025
Visit Reason
Original investigation of FRI IL 198774 for licensing compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes during this original licensing investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
The survey was conducted to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The facility was found to be in compliance with the applicable assisted living regulations during this survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2025
Visit Reason
The document is a plan of correction related to a facility-reported incident #194673 and compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations during this survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The document is a Plan of Correction submitted in response to a complaint investigation survey conducted on June 12, 2025, regarding failure to address specific behaviors in a resident's service plan.
Complaint Details
The survey type is complaint investigation (Complaint 2565263 / IL 194169). The deficiency was substantiated as evidenced by the facility's plan of correction addressing the issues.
Findings
The facility failed to address specific behaviors with interventions for one of three sampled residents, specifically inappropriate touching and grabbing of staff and masturbation in public areas. The facility responded with a revised service plan addressing these behaviors and interventions.
Deficiencies (1)
Failure to address specific behaviors with interventions for one of three sampled residents, including inappropriate touching and grabbing of staff and masturbation in public areas.
Report Facts
Survey Date: Jun 12, 2025
Facility Response Date: Jun 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Netzke | Director of Assisted Living | Signed the Plan of Correction and provided facility comments on licensure findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as an original investigation of Complaint 2565263 / IL 194169 regarding the facility's failure to address specific resident behaviors in service plans.
Complaint Details
Original investigation of Complaint 2565263 / IL 194169. The complaint was substantiated by findings that the service plan did not address the resident's sexual behaviors.
Findings
The facility failed to address sexual behaviors exhibited by one resident (R1) in the service plan, despite documentation and staff acknowledgment of these behaviors. The current service plan dated 5/13/25 did not include interventions for these behaviors.
Deficiencies (1)
Failure to address specific behaviors with interventions in the service plan for one resident exhibiting sexual behaviors.
Report Facts
Complaint number: 2565263
Resident sample size: 3
Resident admission date: Jun 18, 2024
Service plan date: May 13, 2025
Inspection date: Jun 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | E3 stated observations of resident sexual behaviors and redirection instructions | |
| Memory Care Coordinator | E2 confirmed sexual behaviors were not addressed in service plans |
Inspection Report
Original Licensing
Deficiencies: 0
Date: May 4, 2025
Visit Reason
Original investigation of FRI IL 191107 for licensing compliance.
Findings
The establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
The survey was conducted to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
The document is a Plan of Correction submitted by Westminster Village in response to licensure findings related to failure to notify administration of an allegation of misappropriation of resident property during a survey conducted on March 28, 2025.
Complaint Details
The visit was complaint-related based on an allegation of misappropriation of resident property. The facility failed to notify administration timely about the allegation.
Findings
The facility failed to notify administration for three days of an allegation of misappropriation of resident property (missing money) for one resident out of three reviewed for theft. The facility responded by providing additional education to team members on the policy for Abuse and Neglect Prevention and Reporting.
Deficiencies (1)
Failure to notify administration for three days of an allegation of misappropriation of resident property (missing money) for one resident of three reviewed for theft.
Report Facts
Survey Date: Mar 28, 2025
Facility Response Date: Apr 17, 2025
Completion Date: Apr 17, 2025
Residents reviewed for theft: 3
Days failed to notify administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Netzke | Director of Assisted Living | Signed the Plan of Correction and named in the response |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of misappropriation of resident property (missing money) involving one resident.
Complaint Details
The complaint involved an allegation of theft of $700 from resident R1's purse. The facility did not notify Administration until three days after being informed of the missing money. The allegation was investigated through interviews and record review, but the missing money was not recovered and no staff were identified as responsible.
Findings
The facility failed to notify Administration within three days of the allegation of missing $700 from a resident's purse. Interviews and record reviews confirmed the delay in reporting and that staff were unaware of the missing money during the relevant time frame.
Deficiencies (1)
Failure to notify Administration within three days of an allegation of misappropriation of resident property (missing money) for one resident.
Report Facts
Amount of missing money: 700
Days delayed in notification: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director | Interviewed regarding the allegation and notification delay |
| E3 | Campus Director of Nursing | Verified staff notification procedures |
| E9 | Receptionist | Notified by resident's daughter about missing money and sent email notification |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 22, 2025
Visit Reason
Annual Licensure survey and original investigation of FRI IL 183762 were conducted to assess compliance with service plan regulations.
Findings
The facility failed to revise service plans as needed for two of six sampled residents, specifically not addressing a venous ulcer for resident R4 and not updating fall risk interventions for resident R1 after multiple falls.
Deficiencies (2)
Failed to revise the service plan to address a venous ulcer on resident R4's right lower leg.
Failed to revise the service plan for resident R1 after falls to implement interventions to reduce fall risk.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director | Confirmed that R4's venous ulcer was never addressed on the service plan. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
The document is a Plan of Correction responding to an Annual Licensure survey conducted on January 21-22, 2025, addressing deficiencies found during the survey.
Findings
The surveyor alleged that the facility failed to revise the service plan as needed for two of six sampled residents following significant changes in their physical, cognitive, or functional condition.
Deficiencies (1)
Failure to revise the service plan as needed for two of six sampled residents after significant changes in condition.
Report Facts
Survey Dates: Survey conducted from 2025-01-21 to 2025-01-22
Facility Response Date: Facility response date is 2025-02-07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Netzke | Director of Assisted Living | Named in facility comments and signature on Plan of Correction |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 14
Date: Apr 10, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Westminster Village nursing home.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, injury investigations, care plan meetings, change in condition documentation, pressure ulcer care, accident prevention, catheter care, nutrition management, respiratory care, psychotropic medication assessments, food labeling, infection control, immunizations, and COVID-19 vaccination documentation.
Deficiencies (14)
F 0554: Facility failed to assess residents' ability to self-administer medications and lacked physician orders for bedside medication storage for three residents.
F 0610: Facility failed to investigate an injury of unknown origin (rib fractures) for one resident.
F 0657: Facility failed to conduct care plan meetings for one resident as required.
F 0684: Facility failed to document and follow up on a change in condition (right elbow swelling) for one resident.
F 0686: Facility failed to complete comprehensive wound assessments for new pressure ulcers for two residents.
F 0689: Facility failed to secure oxygen canisters, thoroughly investigate falls, and implement fall interventions for two residents.
F 0690: Facility failed to perform complete urinary catheter care, prevent cross contamination, and maintain dignity bags for catheter collection bags for three residents.
F 0692: Facility failed to provide feeding assistance, implement nutritional recommendations, evaluate supplement intake, notify physician of weight loss, and ensure dietitian evaluation for two residents with severe weight loss.
F 0695: Facility failed to obtain orders for oxygen, failed to store, change, and label oxygen and nebulizer tubing properly, and failed to clean a humidifier for four residents.
F 0758: Facility failed to complete psychotropic medication assessments accurately, quantify behaviors, and attempt nonpharmacological interventions for two residents.
F 0812: Facility failed to label opened prepared foods with date and time in the refrigerator, affecting all residents.
F 0880: Facility failed to implement enhanced barrier precautions including gown use and signage for residents with indwelling devices or wounds.
F 0883: Facility failed to maintain documentation of immunization status and offer/administer Pneumococcal and Influenza vaccines for three residents.
F 0887: Facility failed to offer and administer COVID-19 vaccination boosters and document vaccination status for two residents.
Report Facts
Residents in sample list: 31
Facility midnight census: 90
Weight loss percentage: 16.65
Weight loss percentage: 15.6
Number of meals with 0-25% consumed: 11
Number of meals with 26-50% consumed: 28
Number of meals refused: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Confirmed multiple deficiencies including medication orders, oxygen storage, and vaccination documentation. |
| V3 | Assistant Director of Nursing | Provided fall investigation documentation and vaccination process information. |
| V20 | Registered Dietitian | Evaluated residents' nutrition and provided recommendations. |
| V10 | Care Plan Coordinator | Discussed care plan meetings and wound assessments. |
| V7 | Registered Nurse | Provided information on medication orders and resident care. |
| V11 | Certified Nursing Assistant | Involved in catheter care and fall interventions. |
| V15 | Certified Nursing Assistant | Involved in catheter care and fall interventions. |
| V22 | Certified Nurse's Aide | Performed catheter care without gown use. |
| V23 | Certified Nurse's Aide | Performed catheter care without gown use. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
The inspection was conducted following a complaint related to a resident's fall and injury due to improper use of assistive devices during transfer.
Complaint Details
The investigation was triggered by a complaint regarding a resident who slipped from a sit-to-stand lift during toileting and sustained a shoulder dislocation. The complaint was substantiated as the facility failed to use the appropriate sling type mechanical lift as required by the resident's care plan and therapy notes.
Findings
The facility failed to use the safest assistive devices for one resident at high risk for falls, resulting in the resident slipping from a sit-to-stand lift and sustaining a dislocated shoulder requiring closed reduction. Staff used a sit-to-stand lift instead of the required sling type mechanical lift, leading to the fall and injury.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. This failure caused a resident to slip from a sit-to-stand lift and sustain a dislocated shoulder requiring closed reduction.
Report Facts
Date of incident: Mar 11, 2024
Date of survey completion: Mar 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 | Registered Nurse | Documented incident and assisted resident after fall |
| V8 | Certified Nurse's Aide | Assisted resident during fall incident |
| V9 | Certified Nurse's Aide | Assisted resident during fall incident |
| V4 | Occupational Therapist, Director of Therapy | Verified therapy notes requiring sling type mechanical lift |
| V10 | Nurse Practitioner | Provided statement regarding fall and injury |
| V3 | Assistant Director of Nursing | Notified about incident and involved in hospital transfer |
Inspection Report
Routine
Census: 36
Deficiencies: 6
Date: Jun 23, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care, including resident rights, abuse prevention, respiratory care, medication management, infection control, and facility policies.
Findings
The facility was found deficient in honoring residents' rights regarding advance directives, abuse prevention policy compliance, respiratory care practices, medication regimen reviews to prevent duplicate therapy, medication storage and labeling, and infection prevention and control measures. The facility also lacked a comprehensive water management plan to address Legionella risks.
Deficiencies (6)
F 0578: The facility failed to honor residents' rights to request or refuse treatments by not documenting residents' advance directives or code status in medical records and care plans for two residents.
F 0607: The facility's abuse prevention policy did not include the required 2-hour reporting timeframe to the state survey agency and lacked prohibition of abuse via technology, affecting all 36 residents.
F 0695: The facility failed to maintain respiratory equipment sanitation and proper documentation for oxygen tubing and CPap mask cleaning for four residents.
F 0757: The facility failed to review medication orders to prevent duplicate acetaminophen therapy, risking excess dosage for four residents.
F 0761: The facility failed to label insulin with open dates and failed to secure controlled substances in a locked medication refrigerator for four residents.
F 0880: The facility failed to implement infection control measures to prevent cross contamination of oxygen tubing for a resident isolated with a drug resistant infection and lacked a comprehensive water management plan to reduce Legionella risk for all residents.
Report Facts
Residents: 36
Potential total acetaminophen dosage: 10800
Potential total acetaminophen dosage: 10725
Potential total acetaminophen dosage: 9800
Potential total acetaminophen dosage: 9800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator | Confirmed advance directives/code status documentation issues and abuse reporting timeframe |
| V3 | Assistant Director of Nursing | Confirmed respiratory care deficiencies, medication review practices, and medication storage issues |
| V6 | Registered Nurse | Reviewed medical records and medication carts, confirmed missing POLST forms and medication labeling |
| V9 | Registered Nurse | Provided information on isolation precautions for resident with drug resistant infection |
| V12 | Director of Facilities and Property | Reported lack of comprehensive water system risk assessment and testing |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to adequately notify a resident's family and physician of multiple changes in the resident's condition and to provide appropriate urinary catheter care.
Complaint Details
The complaint investigation focused on the failure to notify the resident's physician and family of changes in condition and inadequate catheter care. The physician and family confirmed incomplete notification. The physician stated the facility did not report important symptoms such as lethargy and hematuria, which delayed hospital transfer.
Findings
The facility failed to ensure timely and adequate notification to the resident's physician and family about significant changes in the resident's condition, including hematuria and oxygen saturation decline. Additionally, the facility failed to document urinary catheter size, orders for catheter care, and to provide consistent catheter care documentation.
Deficiencies (2)
F 0580: The facility failed to notify the resident's physician and family of multiple significant changes in the resident's condition, including hematuria and oxygen saturation decline. Notification was incomplete and delayed, impacting clinical decision-making.
F 0690: The facility failed to identify the size of the urinary catheter, document orders for catheter care, and ensure catheter care was completed and documented for the resident.
Report Facts
Residents Affected: 1
Date of Survey Completed: Jun 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V13 | Registered Nurse (RN) | Named in failure to notify physician and family of resident's condition changes |
| V4 | Physician | Resident's physician who was not adequately notified of condition changes |
| V3 | Assistant Director of Nursing (ADON) | Stated facility could not find documentation of urinary catheter care |
Inspection Report
Census: 34
Deficiencies: 3
Date: Oct 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, dialysis care, and food safety in the nursing home facility.
Findings
The facility failed to accurately document and honor a resident's advance directives regarding life-saving interventions, failed to monitor and provide appropriate care for a resident's dialysis access site, and failed to maintain kitchen equipment in a sanitary condition, posing potential risks to residents.
Deficiencies (3)
F 0578: The facility failed to honor a resident's right to choose to receive or decline treatments by not accurately incorporating cardiopulmonary resuscitation choices into the medical record and plan of care.
F 0698: The facility failed to identify the type of dialysis access and provide monitoring or care to the dialysis access site for a resident receiving hemodialysis.
F 0812: The facility failed to prevent potential cross-contamination and foodborne illness by not maintaining a can opener and mixer in a safe sanitary condition.
Report Facts
Residents residing in the facility: 34
Residents affected by deficiency F 0578: 1
Residents affected by deficiency F 0698: 1
Residents affected by deficiency F 0812: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Reviewed resident R81's medical records and noted missing POLST | |
| Administrator | Provided copy of resident R81's POLST form | |
| Memory Care Director | Communicated with resident R81's Power of Attorney regarding advance directives | |
| Director of Nursing | Confirmed lack of monitoring for resident R8's dialysis site | |
| Certified Dietary Manager/Director of Dining Services | Observed unsanitary conditions of kitchen equipment |
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