Inspection·June 23, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm R85's Electronic Medical Record (EMR) did not document R85's desire to have or not to have life savings interventions. Advance Directives were not documented in R85's electronic medical record. R85's Care Plan dated 6/14/23 documents R85 was admitted to the facility on [DATE] but does not document any Advance Directives/Code Status. Residents Affected - Few On 6/20/23 at 1:20 PM V6 Registered Nurse reviewed R85's Electronic and Paper Medical Record and confirmed R85 does not have a POLST (Physician Order For Life-Sustaining Treatment) form or Advance Directive recorded anywhere in her medical record. V6 stated R85 came from Assisted Living (sister facility) and they may have a copy of R85's Advance Directives/Code Status but it is not currently in her chart. V6 stated the facility considers everyone a full code until the POLST is filled out and signed by the physician. On 6/20/23 at 1:45 PM V1 Administrator confirmed R85's Advance Directives/Code Status should be recorded in her medical record, there should be a physician order for code status, and it should also be on R85's Care Plan. V1 stated R85 was admitted from Assisted Living (sister facility) and usually the Advance Directive/Code Status is obtained from there upon admission however this time it was not. R85's POLST form was requested but never brought into the facility and therefore not recorded in R85's medical record. V1 stated the facility would obtain a copy and have a physician review it and get it in R85's medical record. On 6/20/23 at 2:58 PM V1 Administrator provided a copy of R85's POLST form. R85's POLST form documents V10 (R85's Power of Attorney), on behalf of R85, declined life saving interventions and chose selective treatment only. R85's POLST form is dated 6/20/23 and signed by V11 Nurse Practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 2 of 11 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 06/23/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to develop their abuse prevention policy to include the required 2 hour time frame for reporting allegations of abuse the state survey agency (Illinois Department of Public Health). This failure has the potential to affect all 36 residents residing on the certified parts of the facility. Residents Affected - Many Findings include: The facility policy Abuse Policy - (Facility Name) dated June 2023 documents, This facility will immediately (within 24 hours) report such instance, suspicion, or allegation of abuse, neglect, mistreatment, misappropriation of property, or injury of unknown source to the Illinois Department of Public Health. This statement is repeated Upon receiving a report of an instance, suspicion, or allegation of abuse, neglect, mistreatment, misappropriation of property, and injuries of an unknown source concerning a resident of (Facility Name), the Administrator or Director of Nursing will submit a facility incident report to IDPH (Illinois Department of Public Health) not more than 24 hours after receiving the report. This same policy did not document the required prohibition of abuse through the use of technology, such as audio and video recording of residents. On 6/22/23 at 1:38 pm, V1, Administrator, confirmed the facility's abuse policy directed that allegations of abuse be reported to IDPH within 24 hours. V1 then stated she was not aware that the requirement for reporting abuse allegations to IDPH was 2 hours. The facility's Resident Census and Conditions of Residents dated 6/23/23 documents 36 residents reside in the certified parts of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 3 of 11 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 06/23/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/21/23 at 10:40 AM R24 was wearing her oxygen per nasal cannula. The tubing and humidifier bottle were not dated or initialed for last date changed. Residents Affected - Some On 6/21/23 at 1:30 PM V3 Assistant Director of Nurses (ADON) stated oxygen tubing and humidifier bottles should be changed weekly on Sundays. V3 confirmed this has not been a physician order and has not been documented on the resident's Treatment Administration Record up until now and it should have been. V3 confirmed the nurses should also be dating and initialing the tubing and humidifier bottle when changing them. V3 confirmed this is a standard of practice that should be followed when administering oxygen. V3 stated the facility added the order to change oxygen tubing and humidifier bottles to the POS and TAR today (6/21/23) for all resident's currently receiving oxygen therapy. R24's Physician Order Sheet (POS) dated June 2023 documents R24 is diagnosed with Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure and is currently on Hospice Care. The same POS documents an order for Oxygen at two - ten liters per minute via nasal cannula as needed for Dyspnea. The same POS does not document an order to change oxygen tubing or humidifier bottles. R24's Care Plan dated 4/26/23 documents R24 is on Oxygen therapy due to Congestive Heart Failure and the staff are to provide oxygen as ordered by the physician and change oxygen tubing and humidifier bottle weekly. R24's Treatment Administration Record (TAR) dated June 2023 documents the order to change oxygen tubing and humidifier bottle was added on 6/21/23 and not completed before this date. 4. On 6/21/23 at 10:10 AM R21's Continuous Positive Airway Pressure (CPap) mask was laying on her bedside table. The mask appeared dirty and had debris on the soft plastic that touches the resident's face and mouth. It did not appear to have been cleaned recently. On 6/21/23 at 1:30 PM V3 ADON stated CPap masks and tubing should be cleaned daily. V3 confirmed this is a standard of practice that should be followed when caring for a CPap machine. V3 stated the order to wash the CPap mask was added to R21's Physician Orders as of today (6/21/23). R21's Physician Order Sheet (POS) dated June 2023 documents R21 was admitted on [DATE], is diagnosed with Obstructive Sleep Apnea, and is to use a CPap machine when sleeping. The same POS documents on 6/21/23 an order was added to wash R21's CPap mask daily with soapy water and air dry. R21's Treatment Administration Record (TAR) dated June 2023 documents the order to wash the CPap mask was added on 6/21/23 and not completed before this date. R21's Care Plan dated 6/21/23 documents R21 has a history of oxygen saturation drops due to Obstructive Sleep Apnea and uses a CPap machine. The CPap mask should be cleaned daily with soapy water. The facility's CPap Cleaning Policy dated 5/15/22 documents CPap machines are ordered by the physician and used by individual residents to aid in sleep disorders. Staff are responsible for the cleaning and maintenance of the machine unless otherwise directed. Daily Cleaning includes placing the tubing, the nasal or face mask and headgear (if appropriate) into a sink with warm, soapy water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 4 of 11 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 06/23/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Agitate in the water for approximately five minutes, rinse well with warm water and allow to dry until all moisture is gone. This should be done every morning. Based on observation, interview, and record review, the facility failed to maintain respiratory equipment in a sanitary manner according to facility policy, and failed to follow facility policy for documenting maintenance of respiratory equipment. This failure affects four residents (R7, R10, R21, and R24) out of four reviewed for respiratory care on the sample list of 31. Findings include: 1. On 6/20/23 at 10:36 am, R10 was seated in a cushioned chair in R10's own room. R10's oxygen concentrator was operating at 2.5 liters per minute. R10 was receiving oxygen therapy through nasal cannula prongs inserted directly into R10's nostrils. The nasal cannula tubing and humidifier bottle were not dated to indicate the most recent changing of the tubing and humidifier bottle, and there was no receptacle to contain the nasal cannula tubing when not in use. There was a nebulizer machine on the bedside bureau in R10's room with oxygen tubing attached and the tubing for the nebulizer was likewise undated to indicate when the most recent changing of the tubing was. R10's current Physician Order Sheet (6/21/23) did not document any instructions for changing R10's nasal cannula tubing nor humidifier bottle. R10's Treatment Administration Record (TAR) dated for June 2023 did not document any instructions for the changing of R10's nasal cannula tubing, humidifier bottle, nor nebulizer tubing. This TAR did not document any changes of R10's tubings nor humidifier bottle. 2. On 6/20/23 at 10:40 am, 1:07 pm, and 6/21/23 at 12:40 pm, R7 was laying in bed in R7's own room with an oxygen concentrator operating at 2 liters per minute. The nasal cannula prongs were directly in R7's nostrils as R7 was receiving oxygen therapy at the time of observations. R7's nasal cannula tubing and humidifier bottle were not dated to indicate the most recent changing of the tubing and humidifier bottle. There was not any kind of receptacle to store the tubing in when not in use. R7's current Physician Order Sheet (6/22/23) documents to Change oxygen humidifier and tubing every week, night shift every Wednesday. The facility policy Oxygen Therapy dated 9/10/22 documents, Oxygen tubing will be changed and filter cleaned weekly. The tubing will be stored in a bag or other containment so it does not lie on the floor, along with a date as to when the tubing was changed. The humidifier bottle will be replaced weekly and/ or when empty and dated, documented on weekly oxygen housekeeping list. On 6/21/23 at 10:49 am, V3, Assistant Director of Nursing, stated, The 'weekly oxygen housekeeping list' is the TAR (Treatment Administration Record). V3 continued to state, The nurses did not follow the policy for dating the tubings and humidifier bottles, and they should have been documenting the changes on the TAR. The facility routine is to change the tubings and bottles on Sunday nights and it is just one of those things we do and forget about documenting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 5 of 11 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 06/23/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to review resident's medication orders to prevent duplicate therapy and the potential for excess dosage for four of four residents (R135, R5, R13, R136) reviewed for duplicate medications in the sample list of 31. Residents Affected - Some Findings include: The facility's admission Medication Regimen Review with a Revision date of 10/1/18 documents, An electronic medication regimen review (MRR) will be performed within 72 hours or an agreed upon timeframe of admission by a licensed pharmacist per written authorization from the facility. Significant medications issues identified by the consultant pharmacist during the admission Medication Regimen Review, must be communicated to the prescriber or designee and resolved by 11:59 P.M. the following day, per the IMPACT Act. Procedure 1. The consultant pharmacist will routinely access an electronic file to identify new admissions. 2. The consultant pharmacist will conduct an electronic comprehensive review of each patient's medication therapy. 7. The pharmacist's analysis of the medication regimen includes: 7.2 Review of appropriate dose with special consideration of age, disease state, pharmacodynamics and pharmacokinetics. The 2021-2022 Lexicomp Drug Reference Handbook documents, Safety: Acetaminophen-induced hepatotoxicity, which can be life threatening, has been associated with doses greater than 4 grams a day. 1.) R135's Order Summary Report dated 6/21/23 documents a diagnosis of acute Kidney Failure. This Order Summary documents orders for Acetaminophen Suppository Insert 650 mg (milligrams) rectally every 4 hours as needed for Pain or elevated temperature with a start date of 6/2/23. This has a potential total of 3,900 mg. This Order Summary documents an order for Tylenol Oral Tablet (Acetaminophen) Give 1500 mg by mouth every 12 hours as needed for Pain with a start date of 6/6/23. This has a potential total of 3,000 mg. This Order Summary documents an order for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for Pain or elevated temperature with a start date of 6/2/23. This has a potential total of 3,900 mg. The above prescribed Tylenol/Acetaminophen has the potential to exceed the maximum daily dose of 4 grams. The potential total dosage in 24 hours adds up to 10,800 mg (10.8 grams). 2.) R5's Order Summary Report dated 6/21/23 documents diagnoses including Pulmonary Hypertension and Transient Cerebral Ischemic Attack. This Order Summary documents orders for Acetaminophen Suppository Insert 650 mg rectally every 4 hours as needed for Pain or elevated temperature with a start date of 11/27/22. This has a potential total of 3,900 mg. This Order Summary documents an order for Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Moderate/severe pain with a start date of 1/30/23. This has a potential total of 975 mg. This Order Summary has an order for Tylenol Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth three times a day for pain with a start dated of 3/31/23. This has a potential total of 1,950 mg. This Order Summary has an order for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for Pain with a start date of 12/14/22. This has a potential total of 3,900 mg. The above prescribed Tylenol/Acetaminophen/Norco has the potential to exceed the maximum daily dose of 4 grams. The potential total dosage in 24 hours adds up to 10,725 mg (10.725 grams). 3.) R13's Order Summary Report dated 6/21/23 documents diagnoses including Metabolic Encephalopathy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 6 of 11 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 06/23/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and Acute Kidney Failure. This Order Summary documents an order for Acetaminophen Suppository Insert 650 mg rectally every 4 hours as needed for Pain or elevated temperature with a start date of 10/6/22. This has a potential total of 3,900 mg. This Order Summary documents an order for Acetaminophen Tablet Give 500 mg by mouth every 6 hours as needed for pain with a start date of 10/7/22. This has a potential total of 2,000 mg. This Order Summary documents an order for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for Pain or elevated temperature with a start date of 10/6/22. This has a potential total of 3,900 mg. The above prescribed Tylenol/Acetaminophen has the potential to exceed the maximum daily dose of 4 grams. The potential total dosage in 24 hours adds up to 9,800 mg (9.8 grams). 4.) R136's Order Summary Report dated 6/21/23 documents diagnoses including Cystitis and Hypertension. This Order Summary documents an order for Acetaminophen Oral Tablet 500 mg (Acetaminophen) Give 2 tablets by mouth two times a day with a start date of 6/12/23. This has a potential total of 2,000 mg. This Order Summary documents an order for Acetaminophen Suppository Insert 650 mg rectally every 4 hours as needed for Pain or elevated temperature with a start date of 6/12/23. This has a potential total of 3,900 mg. This Order Summary documents an order for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for Pain or elevated temperature with a start date of 6/12/23. This has a potential total of 3,900 mg. The above prescribed Tylenol/Acetaminophen has the potential to exceed the maximum daily dose of 4 grams. The potential total dosage in 24 hours adds up to 9,800 mg (9.8 grams). On 6/22/23 at 1:38 PM, V3 Assistant Director of Nursing stated regarding the Tylenol that the pharmacist reviews the medication records but not sure if they review for duplicate Tylenol therapy. V3 confirmed if the Tylenol are separate orders in the computer that there is nothing to stop them from giving too much Tylenol. V3 stated that it is probably a mixture between what they come back from the hospital with and the facility's standing orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 7 of 11 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 06/23/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to document an open date on insulin when opened and failed to secure a controlled substance in a medication refrigerator for four of four residents (R15, R137, R21, R87) reviewed for medication storage and labeling in the sample list of 31. Findings include: The facility's Storage and Expiration Dating of Medications, Biologicals policy with a revision dated of 7/21/22 documents, 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has shortened expiration date once opened or opened. 5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g. {example} needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The facility's Storage and Expiration Dating of Medications, Biologicals policy with a revision date of 7/21/22 documents, 12. Controlled Substances Storage: 12.1 Facility should ensure that Schedule II - V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e. {for example}, a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). 12. 3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. 12.4 Controlled Substances stored in the refrigerator must be in a separate container and double locked. 1.) R15's Order Summary Report dated 6/22/23 documents a diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and has order for Humalog KwikPen Subcutaneous Solution Pen injector Inject as per sliding scale with a start date of 4/8/23. This Order Summary documents an order for HumuLIN 70/30 KwikPen Subcutaneous Suspension Pen-injector (70-30) 100 unit/ml (milliliter) inject 18 units subcutaneously one time a day with a start date of 6/7/23. On 6/22/23 at 8:35 AM, V6 Registered Nurse completed a medication cart review. R15's HumuLIN 70/30 (insulin) vial with approximately 1/4 of the vial remaining was not dated with an open date. R15's Humalog Kwik Pen (insulin) was not dated with an open date and had been used. R15's Humilin 70/30 Kwik Pen injector was not labeled with an open date and had been used. 2.) R137's Order Summary Report dated 6/22/23 documents a diagnosis of Type 2 Diabetes with an order for Insulin Lispro 100 unit/ml (milliliters), Inject 10 units subcutaneously three times a day with a start date of 6/14/23. On 6/22/23 at 8:35 AM, V6 completed a medication cart review. R137's Insulin Lispro 100 unit/ml did not have an open date documented on the insulin vial. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 8 of 11 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 06/23/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3.) R21's Order Summary Report dated 6/22/23 documents a diagnosis of Type 2 Diabetes Mellitus with an order for Insulin Deglu[DATE] unit/ml, inject 60 units subcutaneously one time a day with a start date of 6/14/23. On 6/22/23 at 8:35 AM, V6 completed a medication cart review. R21's Insulin Deglu[DATE] unit/ml injector pen was not labeled with an open date. V6 confirmed there was no open date labeled on R15, R137 and R21's insulin. 4.) R87's Order Summary Report dated 6/22/23 documents diagnoses including Chronic Obstructive Pulmonary Disease and Alzheimer's Disease with an order for Morphine Sulfate (Concentrate) Oral Solution 20 mg (milligrams)/ml (milliliters) give 0.25 ml by mouth every two hours as needed for moderate/severe pain or shortness of breath with a start date of 6/5/23. On 6/22/23 at 8:35 AM, V6 completed a medication room review. The medication refrigerator was not locked and the drawer inside the refrigerator that had a lock on it was not locked. V6 opened the drawer and was unaware that there was medication inside the drawer. V6 confirmed R87's Morphine was inside the unlocked drawer. V6 took the Morphine and stated that V6 would get it logged into the narcotic count book. On 6/22/23 at 1:38 PM, V3 Assistant Director of Nursing stated that insulin should be dated as soon as it is opened and confirmed that R87's Morphine should have been locked in the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 9 of 11 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 06/23/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Failures at this level required more than one deficient practice statement. Residents Affected - Many A. Based on observation, interview, and record review, the facility failed to implement infection control measures to protect oxygen tubing from cross contamination for a resident isolated with a drug resistant infection. This failure affects one resident (R10) out of four reviewed for respiratory care on the sample list of 31. B. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 36 residents in the facility. Findings include: a. On 6/20/23 at 10:36 am, there were posted signs on R10's room door to indicate R10 was being isolated with contact precautions requiring gown and gloves to be worn in the room. R10 was seated in a cushioned chair in R10's own room. R10's oxygen concentrator was operating at 2.5 liters per minute. R10 was receiving oxygen therapy through nasal cannula prongs inserted directly into R10's nostrils. There was no receptacle to contain the nasal cannula tubing when not in use. The nasal cannula tubing was not dated to indicate when the most recent change of tubing had been. R10's current Physician Order Sheet (6/22/23) documents, Maintain contact isolation due to multi-drug resistant organism in urine, dated as initiated 6/19/23. On 6/20/23 at 2:50 pm, V9, Registered Nurse, stated, (R10) is in isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) in the urine, to be safe we gown and glove to go in the room. On 6/20/23 at 2:53 pm, R10 was laying in bed and the nasal cannula tubing was laying on the floor between R10's chair and the oxygen concentrator so that the nasal prongs were in direct contact with the carpeted floor. There was not any kind of receptacle present to contain the nasal cannula while not in use. On 6/21/23 at 10:13 am, R10 was in bed in R10's own room, laying supine, with the head of the bed elevated. R10 was receiving oxygen therapy with the nasal cannula prongs directly in R10's nostrils. R10's nasal cannula tubing was not dated to indicate the tubing had been changed from the point when the tubing was laying on the floor. R10's current Physician Order Sheet (6/21/23) did not document any instructions for changing R10's nasal cannula tubing. R10's Treatment Administration Record (TAR) dated for June 2023 did not document any changes of R10's nasal cannula tubing. On 6/21/23 at 10:49 am, V3, Assistant Director of Nursing, stated that the tubing being left on the floor, and then (R10) using the tubing, was very much so a concern. The facility policy Oxygen Therapy dated 9/10/22 documents, The tubing will be stored in a bag or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 10 of 11 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 06/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many other containment so it does not lie on the floor, along with a date as to when the tubing was changed. The humidifier bottle will be replaced weekly and/ or when empty and dated, documented on weekly oxygen housekeeping list. On 6/21/23 at 10:49 am, V3, Assistant Director of Nursing, stated, The 'weekly oxygen housekeeping list' is the TAR (Treatment Administration Record). b. The facility water management plan (8/2022) fails to fully document the required facility water system risk assessment where Legionella and other pathogens could grow and spread in the facility water system. The same record did not document the required consideration of the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) standard or the (CDC) Centers for Disease Control and Prevention Water Management Program toolkit. The plan did not identify any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system. On 6/23/2023 at 10:30AM, V12 (Director of Facilities and Property) reported not being aware if the facility completed a comprehensive water system risk assessment for waterborne infections and reported the facility was not testing water for the presence of waterborne pathogens. V12 was not aware of any additional policy to the one above. The Resident Census and Conditions of Residents report (6/23/2023) documents 36 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145400 If continuation sheet Page 11 of 11