Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure ongoing assessment, identifying, and
reporting of new skin impairment for a resident that is at risk. The facility also failed to follow manufacturer
recommendation when using a low air loss mattress. This deficiency affects one (R12) of three residents in
the sample of 20 reviewed for Wound/Skin Prevention Management.
Residents Affected - Few
Findings include:
On 10/31/23 at 11:50AM, observed R12 lying in low air loss (LAL) mattress bed. R12 said that his buttocks
hurt. Called V9 (Registered Nurse/RN) to check and assess resident's back. Observed multi-layer linen over
the LAL mattress. There was a flat sheet, folded linen in quarter, 2 cloth pads and disposable chucks over
the LAL mattress. R12 is wearing disposable brief. V9 said that R12 should only be on flat sheet over the
LAL mattress. There should not be multi-layers of linen because it depletes the purpose of the LAL
mattress.
On 10/31/23 at 12:07pm, informed V2 (Director of Nursing/DON) of above observation. V2 said that R12
should only be on a flat sheet over the LAL mattress. There should not be multi layers of linen. Requested
the policy on wound care prevention and LAL mattress protocol.
On 11/1/23 at 10:30AM, V14 (Wound Care Nurse/WCN) said that R12 has history of MASD (Moisture
Associated Skin Disorder) that was healed months ago. Observed V13 (Certified Nursing Assistant/CNA)
reposition R12 so V14 could do a skin assessment on the sacral area. Observed R12 had MASD with open
wounds on both the right and left buttocks with white paste medication applied. V14 cleansed the sacral
area, assessed, and measured the open wounds. V14 said that R12 has MASD with open wound on left
para sacral measures 6cm x 3.5cm x 0.2cm and right para sacral measures 4cm x 3.5cm x 0.2cm. V14 said
that both has superficial open wound. V14 said that he was not aware that R12 had re-opened his MASD.
He has not seen him since he healed the MASD months ago. V14 said that nurses and CNAs should notify
him if they observed the open wound or any skin impairment. Any skin impairment should be assessed,
notify the physician to obtain appropriate treatment and update family member for wound treatment and
management.
On 11/1/23 at 10:35AM, V13 (CNA) said that she did not report it to the nurse because she has seen R12
with the open wound on sacral area since last week.
On 11/2/23 at 10:22AM V14 (WCN) said that he is responsible for skin assessment to all residents, to
prevent and treat wound, and to implements wound care interventions. V14 said that R12 was initially
admitted on [DATE] with admission Braden scale/skin assessment indicating at high risk for skin
impairment. R12 had facility acquired MASD on 3/29/23. It was healed on 5/26/23. R12's most recent
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
145026
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145026
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Place
3200 Grant Street
Evanston, IL 60201
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Braden scale/skin assessment done on 10/26/23 indicating at high risk for skin impairment. V14 has not
seen and assessed R12 since wound healed. He did not do weekly skin assessment for R12 because he
does not have skin impairment. He only does weekly assessment if resident has active wound. Weekly skin
assessment should be done be nursing and documented in progress notes. There was no skin impairment
reported to him by the nurses and CNAs for R12. He only found out about R12's re-opened MASD when
the surveyor asked him to do the skin assessment. V14 said that nurses and CNAs should notify him if they
observed open wound or any skin impairment. Any skin impairment should be assessed, notify the
physician to obtain appropriate treatment and update family member for wound treatment and
management. V14 said that there should be no multilayers of linen over the LAL mattress. Only a flat sheet
and 1 cloth pad. V14 is not sure if they have policy or protocol for using LAL mattress.
On 11/2/23 at 10:57AM, V2 (DON) said that when CNAs observe any open wound or skin impairment, they
notify the nurse. The nurse then should assess the skin impairment, call the physician or Nurse Practitioner,
and update the family member.
R12 is admitted on [DATE] with diagnosis listed in part but not limited to Muscle weakness, Post polio
syndrome, Noncompliance with medical treatment regimen, Malignant neoplasm of prostate. Active
physician order sheet indicates: Remedy Phytophex Z-Guard (Zinc Oxide)17-57% topical paste applies to
sacral/buttocks/groin/perineal/scrotal areas post soap and water wash two times daily and as needed.
Weekly skin assessment. Low air loss mattress by shift. Care plan indicates: R12 is at risk for pressure
ulcer related to weakness, impaired mobility, incontinence, history of comminuted fracture of posterolateral
aspect of humeral head and a fracture line at anatomic neck of left humerus, history of polio lifelong with
left side weakness/flaccid. He prefers to stay in bed and refused to get out of bed when encouraged.
R12's wound assessment completed by V14 (WCN) on 11/1/23 indicates: Left para sacral MASD measures
6cm x3.5cm x0.2cm, 75% bright red, 25% non-granulating tissues. Right para sacral MASD measures
4cmx 3.5cmx 0.2cm, 80% bright red, 20% non-granulating tissues.
Facility's policy on Prevention and healing of pressure injuries and non-pressure related injuries indicates:
I. Purpose: Residents at this facility will not develop clinically avoidable pressure injuries. Resident admitted
with pressure injuries will receive care and services to promote healing and prevent further injuries.
Residents with non-pressure related injuries will receive care and services according to current standards
of practice.
II. Statement of policy:
Provides care and services to:
*Promote the prevention of pressure injury development
Procedure:
c. Weekly physical assessment of skin throughout stays.
C. Monitor/evaluate:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145026
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145026
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Place
3200 Grant Street
Evanston, IL 60201
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
a. Nursing assistant observes and reports alteration in skin integrity. Notify nurse of any change in skin
condition.
Level of Harm - Minimal harm
or potential for actual harm
b. Nurse evaluate skin condition weekly or more often if indicated.
Residents Affected - Few
Facility's policy on Use of Support Surfaces indicates:
Policy explanation and compliance guidelines:
6. Support surfaces will be utilized in accordance with manufacturer recommendation.
8. Limit the amount of linen and pads placed on the bed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145026
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145026
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Place
3200 Grant Street
Evanston, IL 60201
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to use appropriate PPE (Personal
protective equipment) for a resident on droplet and contact isolation. The facility also failed to perform hand
hygiene after removing and donning gloves during incontinence care. This deficiency affects one (R42) of
three residents in the sample of 20 reviewed for infection control.
Residents Affected - Few
Findings include:
On 11/1/23 at 10:00am observed R42's door with a posting of Special Droplet/contact precautions.
On 11/1/23 at 10:20AM, observed V13 (Certified Nursing Assistant/CNA) after providing incontinence care
to R42. V13 rolled the soiled linen toward R42 and tucked it underneath her while V14 (Wound Care
Nurse/WCN) was holding R42 in a side lying position. V13 removed her soiled gloves, took a clean flat
sheet, and covered the mattress with her bare hands. V13 realized that she was not wearing gloves. She
donned gloves without hand hygiene.
On 11/1/23 at 10:35AM, informed V13 (CNA) and V14 (WCN) of the observation made while observing
incontinence care and wound care to R42. V13 said that she should wear gloves when making the bed for a
resident on isolation precaution. She should have washed her hands after removing and before wearing
gloves during incontinence care.
On 11/1/23 at 10:55AM conducted an interview with V3 (Infection Preventionist). Informed V3 of the
observation made with V13 (CNA). V3 said that V13 should perform hand hygiene after removing gloves
and donning gloves during incontinence care.
Facility's policy on Isolation for Infectious Diseases 7/18/23 indicates:
Purpose: To prevent transmission of infectious disease.
Special Droplet/contact precaution- Residents who are suspected to be infected with microorganism
transmitted by droplets (large-particle droplets) that can be generated by the resident coughing, sneezing
talking or procedures such as suctioning:
11. Sets up isolation equipment as follows:
c. Places bedside cabinet or isolation cart outside resident's room and ensures stock of clear garbage
bags, red plastic infectious waste bags, yellow or blue plastic linen bags (depending on color used at
community), gloves, gowns, eye protection, and masks and single use thermometers, stethoscope, and
sphygmomanometer as appropriate.
Facility's poster for Special droplet/contact precautions from CDC posted outside R12's door indicates:
In addition to standard precautions. Only essential personnel should enter this room. If you have questions,
ask nursing. Everyone must: including visitors, doctors, and staff.
1. Clean hands when entering and leaving the room.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145026
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145026
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Place
3200 Grant Street
Evanston, IL 60201
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
2. Wear Mask. (Fit tested N95 or higher required when performing aerosol-generating procedures)
Level of Harm - Minimal harm
or potential for actual harm
3. Wear eye protection. (Face shield or goggles)
4. Gown and glove at the door.
Residents Affected - Few
5. Keep door closed.
6. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment.
Facility's policy on Hand hygiene 9/21/21 indicates:
I. Purpose: To prevent the spread of infection and to maintain asepsis.
II. Statement of policy: Hand hygiene is essential for preventing the spread of infectious organism in health
care settings. The center for Disease Control and Prevention (CDC) and Illinois Department of Public
Health (IDPH) recommend the routine use of alcohol- based hand rubs (ABHR) over soap and water due to
improved adherence, effectiveness, and accessibility except in situations where soap/water handwashing is
specifically recommended. This table below provided by the CDC summarizes the recommended uses of
the two forms of hand hygiene.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145026
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 3, 2023 survey of WESTMINSTER PLACE?
This was a inspection survey of WESTMINSTER PLACE on November 3, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESTMINSTER PLACE on November 3, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.