Health inspection·March 26, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction. Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. This Care Plan documents R1 is High Risk for Falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired, has functional limitations to all four extremities, uses a manual wheelchair and is totally dependent to roll wheelchair 150 Feet. This MDS also documents R1 is dependent for Sit to Stand, Toilet Transfer, and Toilet hygiene. R1's Care Profile Audit Report printed 3/26/24 documents: On 2/21/24 at 11:26AM Sit-to-Stand (lift). On 2/21/24 at 2:43PM (Sling type mechanical lift). On 2/27/24 at 7:36AM (Sling type mechanical lift). R1's Physical Therapy Note dated 3/10/24 by V12, Physical Therapy Assistant (PTA) documents Precautions/Contraindications: Fall risk, Lower extremity Edema, Low Activity tolerance, (sling type Mechanical Lift) transfer, Left Lower Extremity Numbness, Limited bilateral shoulder flexion, Bilateral Hand and Wrist Edema, and Left Quadriceps Weakness. R1's Incident Note dated 03/11/2024 at 12:39PM by V6, Registered Nurse (RN) documents (R1) assisted to toilet with Sit to stand lift, two CNAs used sit to stand trial to clean (R1) when (R1) slid out of sling and was lowered by CNA to floor. Range of Motion Within Normal Limits, (R1) complains of pain in Right upper arm. (R1) assisted by three staff and (sling type mechanical lift) to bed. (R1) complains of increasing pain in Right shoulder and inability to move. Grip equal and pulses even bilaterally. Power of Attorney present and requesting (R1) to be seen. Ambulance called and R1 sent to emergency room at approximately 11:45AM. R1's emergency room report from 3/11/24 at 4:11PM documents reports to Emergency Department status (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 2 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 03/26/2024 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)