Cycle 1
Health 2024-04-10 · Fire 2024-04-10
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bloomington, IL
Westminster Village
4-star overall rating with 3-star inspections with $12,149 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2025 East Lincoln Street, Bloomington, IL
(309) 663-6474
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-08-01
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.35
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.22
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.45
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
643
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0201
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.86
Baseline 19.57% · Performance 17.79% · Measure score 7.86 · Achievement 7.86 · Improvement 6.51
Healthcare-associated infections
6.20
Baseline 4.88% · Performance 5.98% · Measure score 6.20 · Achievement 6.20 · Improvement 0
Total nurse turnover
7.29
Baseline 26.67% · Performance 33.90% · Measure score 7.29 · Achievement 7.29 · Improvement 0
Adjusted total nurse staffing
5.10
Baseline 4.63 hours · Performance 4.53 hours · Measure score 5.10 · Achievement 5.10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.24% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 2.76% · Lower 95% interval 5.36% |
| Discharge to community | 45.69% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 42.75% · Lower 95% interval 36.04% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.04% |
95.27%
2.8 pts better
|
Numerator 100 · Denominator 102 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 102 |
| Discharge self-care score | 40.45% |
53.69%
13.2 pts worse
|
Numerator 36 · Denominator 89 |
| Discharge mobility score | 40.45% |
50.94%
10.5 pts worse
|
Numerator 36 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 4 · Denominator 102 · Adjusted rate 4.21% |
| Healthcare-associated infections requiring hospitalization | 5.98% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 2.5% · Lower 95% interval 3.37% |
| Staff COVID-19 vaccination coverage | 4.4% |
8.2%
3.8 pts worse
|
Numerator 8 · Denominator 182 |
| Staff flu vaccination coverage | 96.75% |
42%
54.8 pts better
|
Numerator 238 · Denominator 246 |
| Discharge function score | 51.69% |
56.45%
4.8 pts worse
|
Numerator 46 · Denominator 89 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 26.56% |
25.2%
1.4 pts better
|
Numerator 17 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
2.0
1.6 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.8% · Q4 3.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 42.7% |
50.3%
7.6 pts better
|
11.4%
31.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 50.0% · Q3 26.9% · Q4 19.2% · 4Q avg 42.7% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.5%
3.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.0% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
18.5%
4.4 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 16.0% · Q4 18.2% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
22.8%
5.3 pts better
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.3% |
17.2%
7.1 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
15.0%
0.7 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 20.0% · Q4 4.5% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
1.1%
2.5 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.7% · Q3 1.9% · Q4 4.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
1.7%
3.5 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 16.0% · Q4 8.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
21.3%
5.8 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 29.8% · Q3 36.7% · Q4 24.5% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 9.9% |
5.2%
4.7 pts worse
|
5.1%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 12.8% · Q3 5.9% · Q4 3.7% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
68.8%
30.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
14.0%
7.3 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.3% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.3%
1.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
63.0%
34.9 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
26.2%
1.9 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 17.5% · Expected 17.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-23 · Fire 2023-06-23
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-10-14 · Fire 2022-10-14
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-20
F · Potential for more than minimal harm
2024-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-20
E · Potential for more than minimal harm
2024-04-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-20
F · Potential for more than minimal harm
2023-06-23
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-13
F · Potential for more than minimal harm
2023-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-11
F · Potential for more than minimal harm
2023-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-23
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-06-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-06-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-06
F · Potential for more than minimal harm
2022-10-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-03
F · Potential for more than minimal harm
2022-10-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-03
F · Potential for more than minimal harm
2022-10-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-03
Inspection history
Recent health citations
G · Actual harm
2024-04-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-04-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-04-29
G · Actual harm
2024-03-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-29
F · Potential for more than minimal harm
2023-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-06-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-06-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-06-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-23
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-07
C · Minimal harm
2023-06-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-06-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-19
F · Potential for more than minimal harm
2022-10-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-27
D · Potential for more than minimal harm
2022-10-14
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-10-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-21
Penalties and ownership
What sits behind the stars
$12,149
2024-03-26
Fine
Fine · fine $12,149
Fine
$0
2024-03-26
Payment Denial
Payment Denial · denial start 2024-04-24 · 5 days
5 day denial
Ownership
Armstrong, Carlos
Corporate Director · Individual
Baker, Christine
Operational/Managerial Control · Individual
Beaty, Chad
Corporate Director · Individual
Buettner, Chris
Corporate Director · Individual
Curtis, Sarah
Corporate Director · Individual
Dekeersgieter, Mark
Corporate Director · Individual
Frerichs, Troy
Corporate Director · Individual
Hall, Monica
Corporate Director · Individual
Hinch, Nate
Corporate Director · Individual
Hosea, Arlene
Corporate Director · Individual
Lau, Daniel
Operational/Managerial Control · Individual
Mcclellan, Stephanie
Corporate Director · Individual
Riehle, Matthew
Corporate Officer · Individual
Schill, Kelvin
Corporate Director · Individual
Teichman, Carl
Corporate Director · Individual
Williams, Katie
Operational/Managerial Control · Individual
Williams, Katie
Corporate Officer · Individual
Yont, Greg
Corporate Director · Individual
Nearby options
Other facilities in reach
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Goldwater Care Bloomington
Bloomington, IL
1-star overall rating with 1-star inspections with Special Focus status with $237,807 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Arcadia Care Bloomington
Bloomington, IL
1-star overall rating with 2-star inspections with abuse icon flag with $45,965 in total fines with 14 recent health deficiencies
#3
Loft Rehab & Nursing Of Normal
Normal, IL
1-star overall rating with 1-star inspections with $203,405 in total fines with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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