Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westminster Place during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precaution (EBP) protocols, affecting four residents. Staff improperly disposed of PPE outside resident rooms, and there was a lack of EBP orders and documentation. A private caregiver provided care without PPE, and a resident's room lacked necessary EBP signage and setup, despite having multiple pressure ulcers and a sepsis diagnosis.
The facility failed to provide proper pressure ulcer care for two residents using low air loss mattresses. One resident had multiple layers of linens on the mattress, lacked heel protectors, and experienced improper incontinence care, leading to worsened pressure ulcers. The other resident also had improper mattress use, with a Stage 4 pressure ulcer. Facility policies on support surfaces and pressure injury prevention were not followed.
A resident with multiple health issues, including incontinence, received improper perineal care at an LTC facility. A Wound Care Nurse was observed wiping from rectal to perineum, contrary to the facility's policy of wiping front to back to prevent infections. Additionally, a thick pad lining was improperly used inside the resident's brief, which was not reported to the nursing staff. The Director of Nursing was informed of these deficiencies.
The facility failed to document the count verification of controlled substances during nurses' shift changes for a medication cart. On several occasions, the verification form lacked the initials of the responsible nurses. A registered nurse admitted to counting narcotic medications but forgetting to sign the form. The facility's policy requires both incoming and outgoing nurses to sign the form after counting, but this was not consistently followed.
Infection Control Deficiencies in EBP Implementation
Penalty
Summary
The facility failed to implement its protocol on Enhanced Barrier Precaution (EBP) for infection control, affecting four residents. Observations revealed that staff did not properly dispose of Personal Protective Equipment (PPE) inside the resident rooms as required. For instance, a CNA and an RN were observed removing and disposing of PPE outside the rooms of residents R42 and R110, contrary to the facility's policy. Additionally, the RN was unaware of the reason for EBP for R42, and there was no documented order for EBP in R110's medical record, despite the resident requiring wound care. Further deficiencies were noted with resident R108, where a private caregiver was observed providing personal hygiene care without using any PPE, despite being informed of the requirement. The facility's Director of Nursing (DON) did not allow access to R108's hospital transfer records, and there was no documentation of the caregiver's non-compliance in the care plan. This indicates a lack of adherence to infection control protocols and documentation practices. Resident R45's room lacked EBP signage, PPE setup, and necessary precautions, despite having multiple stage 3 pressure ulcers and a diagnosis of sepsis. The Infection Preventionist and DON acknowledged the absence of required EBP measures, which should have been implemented upon admission. These findings highlight significant lapses in the facility's infection control management and adherence to established protocols.
Deficiencies in Pressure Ulcer Care and Mattress Use
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, R108 and R110, who were using low air loss (LAL) mattresses. For R108, the facility did not limit the layers of linens on the LAL mattress, which included a fitted sheet, cloth pad, and folded linens, impeding the mattress's function. Additionally, R108's care plan lacked documentation of caregiver noncompliance and education, and the resident did not have bilateral heel protectors as ordered by the physician. The wound care nurse (V6) and certified nursing assistant (V13) also failed to follow proper incontinence care procedures, which could contribute to infection risk. R108's wound care management was further compromised by the use of a thick pad lining inside the disposable brief, applied by the private caregiver, which was against facility policy. The caregiver claimed that the staff was aware and also used the pad lining. The wound care nurse observed worsening conditions of R108's pressure ulcers, including an unstageable ulcer on the sacrum and a Stage 3 ulcer on the left buttocks, with improper cleaning techniques observed during care. Despite these observations, the wound care nurse indicated that the treatment would remain the same. For R110, the facility also failed to limit the layers of linens on the LAL mattress, with a cloth pad observed over the mattress. R110 had a Stage 4 pressure ulcer on the sacrum, with a comprehensive care plan indicating a high risk for further skin impairment. The facility's policies on support surfaces and pressure injury prevention were not adequately followed, contributing to the deficiencies in wound care management for both residents.
Improper Perineal Care During Incontinence Management
Penalty
Summary
The facility failed to ensure proper perineal care during incontinence care for a resident, identified as R108, who was part of a sample of 14 residents reviewed for incontinence care. During an observation, a Wound Care Nurse (V6) and a Certified Nursing Assistant (V13) were preparing to provide wound care to R108. It was noted that a thick pad lining was placed inside the resident's disposable brief, which was against the facility's policy. V13 admitted that the caregiver had been using the pad lining because the resident frequently defecated, but this was not reported to the floor nurse or V6. Additionally, V6 was observed wiping the resident from rectal to perineum, which is contrary to the proper technique of wiping from front to back to prevent infections. R108 was admitted with multiple diagnoses, including pneumonia, Alzheimer's disease, and dementia, and has bladder and bowel incontinence related to impaired cognition and other health issues. The facility's policy on perineal care emphasizes cleaning from front to back to prevent infection and skin breakdown. However, during the observation, V6 did not adhere to this policy, and V13 had to correct the technique. The Director of Nursing (V2) was informed of these concerns, highlighting a lapse in adherence to established care protocols for incontinence management.
Failure to Document Controlled Substance Count Verification
Penalty
Summary
The facility failed to document the count verification of controlled substances during nurses' shift changes for one of the three medication carts reviewed. On multiple occasions, including specific dates in October 2024, the controlled substances count verification form was missing the initials of the nurses responsible for the count. During an observation on October 15, 2024, a registered nurse (RN) acknowledged that she counted the narcotic medications with the 11-7 shift nurse but forgot to sign the verification form afterward. The facility's policy requires that at each shift change, both the incoming and outgoing nurses must sign the controlled medication verification form after counting the medications. This procedure is part of the facility's Controlled Substance Storage Policy, which mandates special handling, storage, disposal, and record-keeping in compliance with federal, state, and other applicable laws and regulations. Despite this policy, the facility did not adhere to the required documentation process, as confirmed by the Nursing Supervisor and the Director of Nursing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Evanston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Estates Of Evanston | 0.4 mi | ★★★★★ | 4 | 0 |
| Warren Barr Lieberman | 0.7 mi | ★★★★★ | 0 | 0 |
| Three Crowns Park | 0.9 mi | ★★★★★ | 2 | 0 |
| Citadel Of Skokie, The | 1 mi | ★★★★★ | 4 | 0 |
| Alden Estates Of Skokie | 1 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.