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 Village during CMS and state inspections, most recent first.
Unsafe water temperatures were found in multiple resident bathroom sinks and showers, with readings above the facility's stated upper limit. The maintenance director confirmed the temperatures were too high. The facility also failed to adequately supervise a severely cognitively impaired resident with Alzheimer’s disease and daily wandering, who repeatedly entered other residents’ rooms and was involved in an incident where he grabbed another resident’s wrists while the resident called for help; staff said 15-minute checks were not enough and that staffing issues sometimes prevented constant supervision.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: A resident with Alzheimer’s disease, severe cognitive impairment, and daily wandering entered another resident’s room uninvited and became physically aggressive, hitting the resident and grabbing both wrists. The other resident, who was cognitively intact, yelled for help until an LPN intervened and removed the aggressive resident. The DON confirmed the physical altercation and that it was documented in the resident’s record.
Two residents with CHF had physician orders and care plan interventions for daily weights, but staff failed to obtain and document these weights on multiple days and did not consistently record reasons when weights were not taken. One resident experienced notable weight gain along with swelling, shortness of breath, and altered mental status before being sent to the hospital, with no documented provider notification of the weight variance. Another cognitively intact resident with leg swelling reported being weighed only weekly despite a daily weight order. Nursing staff, the NP, and the DON all acknowledged that daily weights, documentation of refusals or missed weights, and timely provider notification for significant weight changes were expected under facility policy, but these practices were not consistently carried out.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
The facility failed to provide adequate feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two residents. This resulted in severe weight loss for both residents, with one losing 16.65% of their weight over six months and the other losing 15.6% in two months.
The facility failed to label opened prepared foods with the date and time in the refrigerator, potentially affecting all 90 residents. The Dietary Manager could not determine how long the items had been in the refrigerator and decided to discard them.
The facility failed to obtain orders for oxygen, store, change, and label oxygen and nebulizer tubing per policy, and provide routine cleaning of a humidifier for several residents. Observations revealed uncovered and undated nebulizer equipment, outdated humidification bottles, and oxygen tubing on the floor, with no proper documentation or adherence to facility policies.
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC, affecting five residents. Staff did not wear gowns during urinary catheter care and wound treatments, and there was no EBP signage or PPE available in the rooms of affected residents. The Director of Nursing/Infection Preventionist admitted that the facility did not have an EBP policy in place.
The facility failed to assess the ability of three residents to self-administer medications, resulting in unauthorized medications being found at their bedsides. None of the residents had documented orders or assessments for self-administration, despite the facility's policy requiring such measures.
A resident experienced a fall and was later found to have multiple rib fractures, but the facility failed to investigate the cause of the injuries as required by their Abuse Policy. The DON and Assistant DON were unaware of the fractures until weeks later, indicating a lapse in communication and policy adherence.
A resident's care plan meeting was missed, with the last meeting documented several months ago. The facility's staff acknowledged the oversight, citing a large caseload as a contributing factor.
A resident reported swelling in their right elbow, but the facility failed to document the condition or ensure the resident was evaluated by a physician. Despite the resident's complaints and a nurse's observation, there was no follow-up or proper documentation in the medical record.
The facility failed to complete comprehensive wound assessments for two residents with new pressure injuries. Both residents, who required substantial assistance, had physician's orders for wound care but lacked proper documentation and timely updates to their care plans. The facility's policy did not specify staff responsibilities for initial wound assessments, leading to a lack of awareness and proper care.
The facility failed to secure oxygen canisters and properly implement fall interventions for two residents. Unsecured oxygen cylinders were found near a resident's doorway, and the resident's bed and chair alarms were not consistently connected to alarming devices. Fall investigations were incomplete, lacking documentation on the resident's activities prior to falls and staff interviews.
The facility failed to perform complete urinary catheter care, prevent cross-contamination, and maintain dignity and infection control for three residents. Issues included incomplete cleaning, improper glove use, and uncovered urinary collection bags touching the floor.
The facility failed to complete or accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for two residents. One resident's medical record lacked proper assessments and behavior quantification, while another resident's record did not include nonpharmacological interventions or responses.
The facility failed to document and offer/administer Pneumococcal and Influenza vaccines for three residents, despite having a policy in place. The Assistant Director of Nursing confirmed that the required consent/declination forms were missed.
The facility failed to offer and document COVID-19 vaccination boosters for two residents. One resident's record showed no documentation of education or booster administration, while another's record lacked any vaccination history or status. The Assistant Director of Nursing confirmed that the required documentation was missed for both residents.
The facility failed to use the appropriate assistive device for a resident at high risk for falls, resulting in the resident slipping from a sit-to-stand lift and sustaining a dislocated shoulder. Despite the care plan indicating the need for a sling type mechanical lift, staff used a sit-to-stand lift, leading to the injury.
Unsafe Water Temperatures and Inadequate Supervision for Wandering Resident
Penalty
Summary
The facility failed to maintain hot water supply temperatures in resident bathrooms and showers within safe operating ranges. During observation, multiple resident hand sinks were measured at 116.9 F, 117.8 F, 119.3 F, 120.9 F, 123.0 F, and 123.6 F. The maintenance director stated the facility checked resident bathroom water temperatures weekly and identified an upper limit of 112 F, then rechecked rooms and found hand sink and shower temperatures as high as 123.0 F and 120.2 F, stating the temperatures were "way too high." The resident roster showed the affected rooms belonged to seven residents: R3, R11, R13, R36, R47, R48, and R52. The facility also failed to provide adequate supervision for a resident with a history of wandering. R8's care plan documented Alzheimer's disease, forgetfulness about safety concerns, wandering in his room and hallway without assistance, and a history of wandering. The MDS described R8 as severely cognitively impaired, with daily wandering and behavioral symptoms including hitting, kicking, pushing, and grabbing that could interfere with others and intrude on their privacy. Staff interviews confirmed that R8 wandered frequently into other residents' rooms and was difficult to keep out of those rooms. An incident occurred when R8 entered another resident's room uninvited, stood over the resident's bedside, and held the resident's wrists while the resident yelled for help. The resident reported that R8 had entered the room before, but this was the first time he became physically aggressive. The resident also stated staff did not do a good job supervising R8. Staff later confirmed that although 15-minute checks were being done, they were not sufficient after the incident and that constant supervision was ordered, but staffing shortages and call-offs sometimes prevented enough staff from providing that level of supervision.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse. The abuse prevention, reporting, and investigation policy stated the facility prohibits abuse and defines physical abuse as the willful infliction of injury, including hitting, slapping, rough handling, or unnecessary force. R8 had Alzheimer’s disease, severe cognitive impairment, daily wandering, and physical behavioral symptoms directed toward others, including hitting, kicking, pushing, and grabbing. R8’s care plan and MDS documented that he forgot safety concerns, walked in his room and hallway without assistance, and had a history of wandering into other residents’ spaces. R8 entered R9’s room uninvited and stood over R9’s bed. During the incident, R8 hit R9 and then grabbed both of R9’s wrists while R9 yelled for help. An LPN entered the room and removed R8 from R9’s bedside and redirected him to his room. R9, who was cognitively intact and had impaired mobility, stated that R8 had entered his room uninvited before, but this was the first time R8 became physically aggressive. The LPN confirmed the physical altercation, and the DON confirmed the incident occurred and was documented as a behavior note in R8’s record.
Failure to Obtain and Document Ordered Daily Weights for Residents With CHF
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician-ordered daily weights for residents with congestive heart failure (CHF), and to document reasons when weights were not obtained. One resident with an active diagnosis of heart failure had a physician order for daily weights related to CHF, but the Medication Administration Record showed no weights documented on multiple specified dates. The weight summary showed a significant increase in weight over two days, yet there was no documentation in the electronic medical record that the physician or NP was notified of this variance. Progress notes later documented increased shortness of breath, increased swelling, and altered mental status, leading to transfer to the hospital. The resident’s family member reported concern about fluid retention, swelling, and shortness of breath, and stated the resident was supposed to be weighed daily but was not. The NP and DON both stated the resident should have been weighed daily and that staff should notify the provider for specified weight gains. Another resident with an active diagnosis of heart failure and a care plan focus on ongoing CHF treatment had a physician’s order for daily weights, but the Treatment Administration Record showed that weights were not obtained or documented on multiple dates. The resident, who was cognitively intact, reported leg swelling due to CHF and stated staff weighed them once a week. Nursing staff confirmed the presence of bilateral leg swelling, the use of ace wraps, and that daily weights were an intervention in place, noting that the resident sometimes refused but that refusals should be documented. The DON and other nursing staff acknowledged that daily weights were required per physician order, that reasons for missed weights should be documented, and that nurses are expected to notify the provider for specified weight gains. The facility’s policy on Acute Change in Condition and Clinical Monitoring required daily weights per physician order, documentation in the TAR/MAR, documentation of reasons when weights cannot be obtained, and a nursing assessment of fluid status, which was not consistently followed for these residents.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two residents. Resident R5 experienced a severe weight loss of 16.65% over six months. Despite documented interventions in R5's care plan, there was no evidence of new nutritional interventions after 12/18/23, and significant weight loss was not reported to or evaluated by a physician. Observations showed R5 often struggled to eat without assistance, and staff did not consistently offer the prescribed nutritional supplements or provide necessary feeding assistance. Resident R21 experienced a 15.6% severe weight loss in two months. The facility did not document that R21's significant weight loss was reported to or evaluated by a physician. Additionally, R21 was not consistently provided with the prescribed nutritional supplement, receiving a less nutritious version instead. This discrepancy was not identified or addressed by the dietitian or nursing staff, contributing to R21's continued weight loss. Both residents' care plans included interventions to address their nutritional needs, but these were not consistently implemented or monitored. The facility's failure to follow through with dietary recommendations, provide necessary feeding assistance, and communicate significant weight changes to physicians resulted in severe weight loss for both residents. Observations and interviews with staff and family members highlighted the lack of consistent assistance and monitoring, further contributing to the residents' nutritional decline.
Failure to Label Opened Prepared Foods
Penalty
Summary
The facility failed to label opened prepared foods with the date and time in the refrigerator, which has the potential to affect all 90 residents. On 4/08/24 at 9:00 AM, cole slaw, whipped topping, and sour cream were observed in the refrigerator without labels indicating the date and time they were opened. The Dietary Manager stated that they could not determine how long these items had been in the refrigerator since they were not labeled and decided to discard them. The facility's midnight census as of 4/8/24 was documented as 90.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to obtain orders for oxygen, store, change, and label oxygen and nebulizer tubing in accordance with facility policy, and provide routine cleaning of a humidifier for several residents. Specifically, a humidifier was found in a resident's room without documentation in the medical record or routine cleaning/care. The resident was unsure of the machine's use, and the Director of Nursing (DON) was unaware of its presence, stating that the family brought it in and maintained it. Additionally, nebulizer equipment for another resident was found uncovered and undated, with droplets of medication still present, and there were no documented orders for routine changing of the equipment. Another resident was observed wearing oxygen with an outdated humidification bottle and unlabeled tubing, despite physician orders to change the equipment weekly. Lastly, another resident's oxygen tubing and nasal cannula were found on the floor, with the tubing dated but no storage bag provided, and there were no orders for oxygen administration or routine changing of the equipment in the medical record. The facility's policies for oxygen and nebulizer therapy were not followed, as evidenced by the lack of proper labeling, storage, and routine changing of equipment. The DON confirmed that oxygen and nebulizer tubing should be changed weekly, labeled with a date, and stored in a bag when not in use. However, the observations and interviews revealed that these practices were not consistently implemented, leading to deficiencies in respiratory care for the residents involved. The facility's failure to adhere to its own policies and obtain necessary physician orders contributed to the identified deficiencies in respiratory care management.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC, affecting five residents reviewed for EBP. Certified Nursing Assistants (CNAs) V11 and V15 provided urinary catheter care to Resident 31 without wearing gowns and without EBP signage on the door. Resident 31's care plan indicated the need for contact isolation due to MRSA colonization. Similarly, Resident 97, who had an indwelling urinary catheter, did not have EBP signage on the door, and CNAs V11 and V15 did not wear gowns during catheter care. The Director of Nursing/Infection Preventionist admitted that the facility did not have an EBP policy in place yet, although EBP signage was available. Residents 149, 150, and 33 also did not have EBP signage on their doors, and no PPE was available upon entering their rooms. Resident 149 had a urinary catheter and a pressure area on the right buttock, while Resident 150 had Stage II pressure ulcers on both buttocks. In both cases, the staff did not wear gowns during wound treatments. Similarly, Resident 33 had open pressure ulcers on both buttocks, and staff did not wear gowns during wound treatments or catheter care. The lack of EBP signage and PPE availability, along with the staff's failure to wear gowns, were consistent across all observed cases.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of three residents to self-administer medications. During observations, surveyors found bottles of saline nasal spray and artificial tears at one resident's bedside and bathroom, two tubes of Diclofenac on another resident's nightstand, and a bottle of Flonase and three tablets of medication on a third resident's overbed table. None of these residents had documented orders to self-administer these medications or to keep them at the bedside. Additionally, the residents' medical records lacked assessments of their ability to self-administer medications, despite the facility's policy requiring such assessments and physician orders for bedside medication storage. One resident had moderate cognitive impairment, another had severe cognitive impairment, and the third had moderate cognitive impairment. Interviews with staff confirmed that the residents did not have the necessary orders for self-administration or bedside storage of the medications found. The facility's policy mandates that residents must be assessed and deemed appropriate for self-administration, have a written physician order, and store medications in a manner that prevents access by other residents. The policy also requires that unauthorized medications found at the bedside be reported and returned to the resident's representative, which was not followed in these cases.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident (R16) who was reviewed for accidents. According to the facility's Abuse Policy, injuries of unknown source should be investigated within two hours of notification, and the results should be reported to the Illinois Department of Public Health within five days. R16 experienced a fall on 3/14/2024 and was later found to have multiple rib fractures on 3/17/2024 after being transferred to the hospital. However, there was no documentation that the cause of R16's rib fractures was identified or investigated by the facility. The Director of Nursing (DON) and Assistant DON were unaware of R16's rib fractures until 4/9/2024, indicating a lapse in communication and failure to follow the facility's policy. The DON confirmed that an investigation would have been conducted if they had been notified. The Assistant DON speculated that the rib fractures might not be related to the fall since a chest x-ray on 3/14/2024 did not show any fractures, and suggested that the fractures could be due to R16's coughing. The Administrator began an investigation into the rib fractures on 4/9/2024, but this was after the deficiency had already occurred.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for a resident (R21) as required. R21 stated that the facility does not have care plan meetings with her or her family. The medical record shows that R21 was admitted to the facility and had Minimum Data Sets completed on two occasions. However, the last documented care plan meeting for R21 was on 12/28/23, and no subsequent meetings were held within the required quarterly timeframe. The Social Services Director (SSD) and the Assistant SSD confirmed that R21's care plan meeting was missed and was only scheduled after the oversight was realized. The MDS/Care Plan Coordinator admitted to having a large caseload of 95 residents and acknowledged that R21's care plan meeting was overlooked. The facility's policy mandates care plan reviews and updates at least quarterly, but this was not adhered to in R21's case.
Failure to Document and Follow Up on Change in Condition
Penalty
Summary
The facility failed to document and follow up on a change in condition for one resident who reported swelling in their right elbow. The resident, who is cognitively intact, stated that the swelling started about three weeks ago and had informed the nurses about it. Despite the resident's complaints, there was no documentation in the medical record regarding the swelling or any evaluation by the physician. A registered nurse noticed the swelling and left a note for the physician but did not document the condition in the resident's medical record. The Director of Nursing confirmed that any changes in a resident's condition should be documented in the progress notes, which was not done in this case. The facility's policy on changes in a resident's condition requires that significant changes be reported to the physician and documented in the resident's medical record. However, in this instance, the resident's complaint and the nurse's observation were not properly recorded, and there was no follow-up to ensure the resident was evaluated by the physician. The physician was eventually contacted and ordered an elastic bandage wrap, but this was after the surveyors identified the deficiency.
Failure to Complete Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete a comprehensive wound assessment for two residents with new pressure injuries. Resident R150, who was cognitively intact and required assistance for ADLs, developed two Stage II pressure ulcers. Despite having physician's orders for wound care, there was no comprehensive wound assessment documented. R150 expressed discomfort and reported being left in a wheelchair for extended periods, which exacerbated her condition. The staff did not assist her in moving to a more comfortable recliner, as she requested. Similarly, Resident R149, who was also cognitively intact and required substantial assistance for transfer and toileting, developed a pressure ulcer on the right buttock. The treatment was initiated, but no comprehensive wound assessment was documented, and the care plan was not updated until a week later. The facility's policy did not specify the staff responsible for initial wound assessments, leading to a lack of proper documentation and awareness of the residents' conditions. The Assistant Director of Nursing and the Care Plan Coordinator were unaware of the pressure ulcers until much later, indicating a communication breakdown within the facility.
Failure to Secure Oxygen Canisters and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure oxygen canisters were secure and to thoroughly investigate falls, care plan, and implement fall interventions for two residents. On two separate occasions, unsecured, free-standing oxygen cylinders were observed near a resident's doorway. The Director of Nursing confirmed that the oxygen cylinders were not stored appropriately and should have been placed in the oxygen storage room. The facility's policy on oxygen therapy mandates that oxygen be used and stored safely to ensure resident and staff safety. Additionally, the facility did not properly manage fall interventions for a resident who was at high risk for falls. The resident's bed alarm was not connected to an alarming device on multiple occasions, and the chair alarm was inconsistently used. The resident had a history of falls, including unwitnessed and witnessed falls, but the fall investigations were not thorough. The investigations lacked documentation on the last time the resident was checked on, toileted, or if alarming devices were in place during the falls. There was also no evidence that staff were interviewed regarding these falls. The Assistant Director of Nursing confirmed that the fall investigations could be improved and acknowledged that the bed and chair alarms should have been documented in the resident's care plan and tasks. The facility's policies on falls and fall risk management require staff to identify causes and resident-centered interventions to prevent falls and minimize complications, as well as to monitor the efficacy of alarm use. However, these protocols were not adequately followed in this case.
Deficiencies in Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to perform complete urinary catheter care, prevent cross-contamination during catheter care, and maintain the urinary collection bag in a dignity bag and off the floor for three residents. For one resident, the CNAs did not check or cleanse the creases between the thighs and genitals after a bowel movement, despite performing other aspects of catheter care. Another resident's catheter care was compromised when a CNA did not change gloves after removing the resident's shoes and failed to retract the foreskin and clean the penis. Additionally, a resident's urinary collection bag was observed uncovered, touching the floor, and without a dignity cover in the dining room and during transport out of the dining room. The facility's Nursing Patient Care Policy & Procedure requires hand hygiene, glove application, cleansing of the suprapubic and pubic area, and retraction of the foreskin for uncircumcised males during catheter care. The policy also mandates that urinary drainage bags be kept off the floor and covered for dignity and infection control. The Director of Nursing/Infection Preventionist confirmed that the observed practices did not align with the facility's policy, indicating a failure to adhere to established protocols for catheter care and infection prevention.
Failure to Complete Psychotropic Medication Assessments and Nonpharmacological Interventions
Penalty
Summary
The facility failed to complete or accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for two residents. Resident R5 was admitted with diagnoses including Anxiety Disorder, Major Depressive Disorder, Delusional Disorder, and Paranoid Personality Disorder. The medical record for R5 documented multiple psychotropic medications but lacked proper assessments, behavior quantification, and nonpharmacological interventions. Additionally, there was no assessment for the increased dose of Escitalopram. The Assistant Director of Nursing confirmed these deficiencies during the review. Resident R14 had diagnoses of Anxiety, Depression, and Dementia and was prescribed multiple psychotropic medications. The psychoactive medication assessment for R14 documented behaviors of anxiety and constantly yelling out but did not include any nonpharmacological interventions or responses to such interventions. The Care Plan Coordinator confirmed the absence of documentation for nonpharmacological interventions or responses. The facility's policy requires specific behavior documentation and assessments on admission and quarterly, which were not followed in these cases.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to maintain documentation of immunization status and offer/administer Pneumococcal and Influenza vaccines for three residents out of five reviewed in a sample of 31. The facility's policy, dated April 2024, mandates that residents be offered these vaccines based on CDC guidelines, with the Nursing Department responsible for ensuring administration and documentation. However, the records for three residents (R31, R21, R26) did not show that these vaccines were offered or administered. Specifically, R31's record showed previous vaccinations but no documentation of recent offers, R21's record lacked any immunization information, and R26's record showed an outdated vaccination with no recent offers documented. During an interview, the Assistant Director of Nursing (V3) confirmed that the process involves offering vaccines on admission and reviewing hospital records for immunizations. V3 acknowledged that the consent/declination form was missed for the three residents in question and could not provide documentation showing that the vaccines were offered on admission. This lapse in following the facility's policy and CDC guidelines led to the deficiency noted in the report.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer and administer COVID-19 vaccination boosters to two residents, R31 and R21, as required by their policy. R31's medical record showed that they received a COVID-19 vaccine on 5/3/2022 and were admitted to the facility on an unspecified date. However, there was no documentation that education regarding the COVID-19 vaccination was provided to R31, nor was there any record of a COVID-19 booster being offered or administered. Similarly, R21's medical record did not document that COVID-19 vaccinations were offered or given, nor did it include any vaccine history or status. R21 was admitted to the facility on an unspecified date and had diagnoses of Pneumonia, Anemia, and Cerebral Infarction. During an interview, the Assistant Director of Nursing (V3) stated that Flu, Pneumonia, and COVID vaccines are offered upon admission and that hospital records are reviewed for immunizations. V3 acknowledged that the form for documenting consent or declination of vaccinations was missed for both R31 and R21. The facility's policy, revised in January 2024, mandates that the latest COVID-19 immunizations be made available to all residents upon admission unless medically contraindicated or already immunized. The policy also requires documented consent or refusal of the COVID-19 vaccine, which was not provided for R31 and R21.
Inappropriate Use of Assistive Device Leads to Resident Injury
Penalty
Summary
The facility failed to utilize the safest assistive devices for a resident (R1) who was at high risk for falls. R1, who had multiple diagnoses including chronic kidney disease, congestive heart failure, muscle weakness, and unsteadiness on feet, was moderately cognitively impaired and dependent on assistive devices for mobility and hygiene. Despite R1's care plan and physical therapy notes indicating the need for a sling type mechanical lift for transfers, the staff used a sit-to-stand lift, which was not appropriate for R1's condition. This inappropriate use of the sit-to-stand lift led to R1 slipping from the device and sustaining a dislocated shoulder, which required medical intervention in the form of a closed reduction at the emergency room. On the day of the incident, the registered nurse (V6) and two certified nurse aides (V8 and V9) attempted to clean R1 after a bowel movement using a sit-to-stand lift, despite R1's documented need for a sling type mechanical lift. During the process, R1, who was too weak, slipped out of the sit-to-stand lift and was eased to the floor by the CNAs. R1 complained of pain in the right shoulder, which was later confirmed to be a dislocation requiring emergency medical treatment. The incident was corroborated by interviews with the involved staff and a review of R1's medical records and care plan, which clearly indicated the necessity of using a sling type mechanical lift for all transfers due to R1's high fall risk and physical limitations.
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What surveyors actually found near you
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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 Bloomington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bloomington Rehabilitation & Hcc | 1.7 mi | — | 0 | 0 |
| Goldwater Care Bloomington | 1.9 mi | ★★★★★ | 4 | 0 |
| Arcadia Care Bloomington | 2.9 mi | ★★★★★ | 13 | 1 |
| Loft Rehab & Nursing Of Normal | 3 mi | ★★★★★ | 22 | 0 |
| Luther Oaks | 3 mi | ★★★★★ | 2 | 0 |
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