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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on interview and record review, the facility failed to ensure a family and physician were adequately
notified of multiple changes in a residents condition for one of three residents (R1) reviewed for change in
condition and notification on the sample list of four.
Findings include:
The facility's Change in a Resident's Condition or Status policy dated February 2021 documents the facility
promptly notifies the resident, his/her attending physician and the resident representative of changes in the
residents medical/mental condition and/or status. The nurse will notify the residents attending physician
when there has been a significant change in the resident's physical/emotional/mental condition, need to
alter the resident's treatment significantly, need to transfer the resident to a hospital. A significant change of
condition is a major decline or improvement in the residence status that will not normally resolve itself
without intervention by staff or by implementing standard disease related clinical interventions, impacts
more than one area of the residence health status, requires interdisciplinary review and/or revision to the
care plan. Prior to notifying the physician or health care provider, the nurse will make detailed observations
and gather relevant and pertinent information for the provider. The nurse will notify the resident
representative when there is a significant change in the residence physical, mental, or psychosocial status.
This policy documents the nurse will record in the residence medical record information relative to changes
in the residence medical/mental condition or status.
R1's Progress Notes dated as follows document:
5/4/23 9:31pm, 5/5/23 at 3:16pm, 5/6/23 at 6:38pm, Urinary catheter draining amber urine.
5/5/23 7:07am- Urinary catheter patent and draining medium yellow urine.
5/8/23 2:40pm, Hematuria noted to urinary catheter. There is no documentation V4, R1's Physician was
notified.
5/8/23 5:34pm- Urinary catheter in place, gross hematuria noted. There is no documentation of physician or
family notification of the gross hematuria.
5/17/23 6:32pm- R1's Oxygen (O2) Saturation is 82% on room air. R1 responds with verbal stimuli. R1
appeared to be tired, sleepy. Mild amount of sanguineous drainage noted in R1's urinary catheter. Oxygen
placed at 2 Liters via nasal cannula at this time, O2 Saturation up to 93%. V4, R1's Physician notified.
(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 4
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
06/07/2023
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
5/17/23 8:21pm, R1's condition deteriorated, arousable but fell a sleep, lethargic, speech clear, face pale.
Mild amount of blood in urinary catheter. V4 was notified with orders received to send R1 to the emergency
room.
On 6/6/23 at 8:20am, V5, R1's Family stated V5, V6 and V7, all R1's family had seen R1 on 5/17/23 at
around 2:30pm and R1 was alert, talking, acting as R1 normally does. V5 stated R1 has Prostate Cancer
and at times has blood in R1's urine. V5 stated R1 has required blood transfusions in the past. V5 stated
V5, V6 and V7 had left the facility and V13, Registered Nurse (RN) called V5 and stated R1's oxygen level
was low so V13 had contacted V4, R1's Physician and received orders for Oxygen. V5 stated V13,
Registered Nurse (RN) did not mention R1 was having additional changes in condition at that time. V5
stated when the family had returned to the facility shortly, within an hour after hearing from V13, R1 was
incoherent, reaching out with arms/confused, very hot and evident (R1) had a fever. V5 stated V5 spoke
with V4, R1's Physician who stated V4 had not been adequately informed of R1's condition decline and if
V4 had, V4 would have given orders to send V4 to the hospital sooner than what V4 did.
On 6/7/23 at V7, R1's family visited R1 at the facility on Tuesday May 16th 2023. V7 stated R1 was in good
spirits, still able to sit up in bed and eat meals. V7 stated V5, V6 and V7 went back to the facility on 5/17/23
around 10am and R1 seemed to be a little better and was excited to see family. V7 stated they talked with
R1 for a little bit then left. V7 stated on 5/17/23, V5, V6 and V7 came back to the facility and R1 was asleep
and the family thought R1 was just tired from therapy, so they had left the facility and went to get dinner to
let R1 rest. V7 stated V5, V6 and V7 came back to the facility between 6pm and 7pm after being notified
R1's Oxygen levels had dropped dangerously low and the facility had applied oxygen. V7 stated when V5,
V6 and V7 entered the room, R1 was curled up in a ball like fetal position and shaking, trembling
uncontrollably. V7 stated V13, RN did not seem to know much and said R1's Oxygen was just a little low,
otherwise R1 was okay. V7 stated R1 had declined dramatically from the morning of 5/17/23. V4 told the
family that V4 had not been notified of the change in R1's condition aside from a low Oxygen level and V4
stated R1 needed to go to the hospital.
On 6/6/23 at 12:20pm, V4, R1's Physician stated the facility called V4 on 5/17/23 at around 6:00pm or 6:30
pm to notify V4 that R1's O2 Saturation had dropped low but did not report R1 had additional
signs/symptoms of a change in condition. V4 stated V4 gave orders according to what the facility had
reported to V4 which was low O2 Saturation, including to administer Oxygen and some oral Lasix (Diuretic)
medication due to R1's history of low O2 Saturation with fluid accumulation in the past due to blood product
transfusion. V4 stated V4 was upset that when the facility called V4 regarding R1 on 5/17/23 at around
6:00pm that R1's O2 Saturation had dropped low, V13, Registered Nurse (RN) did not give V4 additional
details of R1's decline to the point of R1's clinical status including the lethargy, hard to arouse. V4 stated it
was not until V5, R1's Family called V4 on 5/17/23 a little bit later, that V4 heard about R1's lethargy and
difficulty to arouse. V4 stated R1 answers questions appropriately and cognitively intact. V4 stated lethargy
in a resident, such as R1 who is alert and cognitively intact and interacts is a sign/symptom that V4 should
be notified of so V4 could ensure V4 is able to make care decisions based on the signs/symptoms.V4
stated V13 told V4 that V13 could arouse R1 so V13 did not report R1's lethargy. V4 stated V4 educated the
nurse that lethargy in a resident who is alert/awake/talkative is a very important sign/symptom to notify V4
of and that the nurse should have notified V4 of R1's lethargy decreased cognition/difficulty to arouse as
those are signs of sepsis. V4 stated if V4 would have been notified of the additional signs/symptoms, V4
could have sent R1 to the hospital sooner than V4 did. V4 stated the facility is at fault for not notifying V4 of
R1's overall condition including additional signs/symptoms as V4 should have been done. V4
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145400
If continuation sheet
Page 2 of 4
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
06/07/2023
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)
F 0580
could not recall being notified of R1's hematuria or gross hematuria on 5/8/23.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145400
If continuation sheet
Page 3 of 4
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
06/07/2023
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on interview and record review, the facility failed to identify the size of urinary catheter used, failed to
document orders for urinary catheter cares and ensure urinary catheter care was completed and
documented. These failures affect one of three residents (R1) reviewed for urinary catheters on the sample
list of four.
Findings include:
R1's Nursing admission Screening/History form dated 5/4/23 documents R1 has a urinary catheter that was
last changed on 5/1/23. There is no documentation of the size of tubing or balloon of R1's urinary catheter.
R1's Order Summary Report documents an order dated 5/4/23 for (urinary) catheter every shift but does
not document details for R1's urinary catheter including the catheter tube size/balloon size, how often to
change R1's urinary catheter or orders for urinary catheter care.
R1's Care Plans dated 5/16/23 documents R1's urinary catheter is to be changed monthly but does not
document details regarding size of tubing or balloon size. These Care Plans document R1 is to receive
urinary catheter care every shift and as needed. R1's Care Plans also document to monitor for signs and
symptoms of Urinary Tract Infections (UTI) including blood tinged urine, deepening of urine color, fever,
chills and altered mental status, but does not document what to do if R1 exhibits signs and symptoms of a
UTI.
On 6/7/23 at 3:55pm, V3, Assistant Director of Nursing (ADON) stated the facility could not find
documentation R1 received urinary catheter care every shift.
The facility did not provide a urinary catheter policy as requested, only aCatheter Procedure policy dated
6/7/23 regarding urinary catheter irrigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145400
If continuation sheet
Page 4 of 4
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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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
FAQ · About this visit
Common questions about this visit
What happened during the June 7, 2023 survey of WESTMINSTER VILLAGE?
This was a inspection survey of WESTMINSTER VILLAGE on June 7, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESTMINSTER VILLAGE on June 7, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
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.