Health inspection·October 14, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor resident's right to choose to receive or decline treatments including life saving interventions by failing to accurately incorporate resident's choices regarding cardiopulmonary resuscitation into their medical record and plan of care according to the facility policy. This failure affects one of one resident (R81) reviewed for advanced directives on the sample list of 23. Findings include: The facility policy Advance Directives, admission Policy dated July 2022 documents the following: (The facility) recognizes an individual's right to formulate an advance directive and will use its best effort to inform its residents of this right. Procedure: 1. Upon admission, the resident or the appropriate surrogate decision maker as outlined by the Health Care Surrogate Act or Powers-of-Attorney, if resident is mentally incapacitated) will be given an informational packet which explains advance directives and the resident's right to formulate same. 2. Social Service / Nurse will request at the time of admission whether or not the resident has executed an advance directive. R81's Physician Order Summary Sheet (POS) dated 10/12/22 documents the following diagnoses: Alzheimer Disease, Unspecified,Chronic Kidney Disease Stage III, Other Specified Liver Disease, and Current Pathological Fracture Right Femur. The same POS does not document Advance Directives. R81's Electronic Medical Record (EMR) was reviewed. R81 EMR did not document R81's desire to have or not to have life savings interventions. Advance Directives were not found in electronic medical record. R81's Care Plan documents R81 was admitted to the facility on [DATE]. R81's same Care Plan documents all three potential directives: 1. Advance directives-DNR (Do Not Resuscitate)-comfort focused. (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: 145400 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 145400 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Village 2025 East Lincoln Street Bloomington, IL 61701 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)