Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WESTMINSTER VILLAGE

BLOOMINGTON, IL · 48 certified beds · Last Life Safety survey April 10, 2024

CMS Certification Number 145400 · first certified August 1985

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within IL

15 citations — more than 50% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (March 2025 to May 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was April 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 15 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

This facility15IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
42022-1072023-0642024-04
Citations at each Life Safety survey
Survey dateCitations
October 14, 20224
June 23, 20237
April 10, 20244

Most-cited tags

Most-cited tags at this facility
K-07123K-03452K-09182K-01331E-00261K-02931K-03531K-09141
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0712Have simulated fire drills held at unexpected times.32024-04-10
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22023-06-23
K-0918Have generator or other power source capable of supplying service within 10 seconds.22024-04-10
K-0133Install a two-hour-resistant firewall separation.12023-06-23
E-0026Establish roles under a Waiver declared by secretary.12023-06-23
K-0293Have properly located and lighted "Exit" signs.12022-10-14
K-0353Inspect, test, and maintain automatic sprinkler systems.12024-04-10
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12022-10-14

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 5
  • Miscellaneous Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Egress Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies5
Miscellaneous Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies1
Emergency Preparedness Deficiencies1
Construction Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 10, 2024 — 4 citations

Citations issued on April 10, 2024
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (May 20, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 15, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 20, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 20, 2024)

June 23, 2023 — 7 citations

Citations issued on June 23, 2023
TagWhat the surveyor checksStatus
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (July 7, 2023)
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (July 10, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (July 13, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (July 12, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (July 11, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (July 6, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (July 6, 2023)

October 14, 2022 — 4 citations

Citations issued on October 14, 2022
TagWhat the surveyor checksStatus
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (November 3, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (November 30, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (November 3, 2022)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (November 3, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.