Inspection Report Summary
The most recent inspection on December 2, 2025, found the facility in compliance with applicable assisted living regulations and no deficiencies were cited. Earlier inspections showed a pattern of some deficiencies related mainly to updating resident service plans and timely reporting of incidents, including failure to address specific resident behaviors and delayed notification of an allegation of misappropriation of resident property. Complaint investigations substantiated issues with service plan interventions for resident behaviors and reporting delays, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were substantiated, with the facility responding through revised service plans and staff education. The inspection history shows improvement over time, culminating in a clean most recent inspection.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 2, 2025
Visit Reason
Original investigation of FRI IL 198774 for licensing compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes during this original licensing investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
The survey was conducted to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The facility was found to be in compliance with the applicable assisted living regulations during this survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2025
Visit Reason
The document is a plan of correction related to a facility-reported incident #194673 and compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations during this survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The document is a Plan of Correction submitted in response to a complaint investigation survey conducted on June 12, 2025, regarding failure to address specific behaviors in a resident's service plan.
Complaint Details
The survey type is complaint investigation (Complaint 2565263 / IL 194169). The deficiency was substantiated as evidenced by the facility's plan of correction addressing the issues.
Findings
The facility failed to address specific behaviors with interventions for one of three sampled residents, specifically inappropriate touching and grabbing of staff and masturbation in public areas. The facility responded with a revised service plan addressing these behaviors and interventions.
Deficiencies (1)
Failure to address specific behaviors with interventions for one of three sampled residents, including inappropriate touching and grabbing of staff and masturbation in public areas.
Report Facts
Survey Date: Jun 12, 2025
Facility Response Date: Jun 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Netzke | Director of Assisted Living | Signed the Plan of Correction and provided facility comments on licensure findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as an original investigation of Complaint 2565263 / IL 194169 regarding the facility's failure to address specific resident behaviors in service plans.
Complaint Details
Original investigation of Complaint 2565263 / IL 194169. The complaint was substantiated by findings that the service plan did not address the resident's sexual behaviors.
Findings
The facility failed to address sexual behaviors exhibited by one resident (R1) in the service plan, despite documentation and staff acknowledgment of these behaviors. The current service plan dated 5/13/25 did not include interventions for these behaviors.
Deficiencies (1)
Failure to address specific behaviors with interventions in the service plan for one resident exhibiting sexual behaviors.
Report Facts
Complaint number: 2565263
Resident sample size: 3
Resident admission date: Jun 18, 2024
Service plan date: May 13, 2025
Inspection date: Jun 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | E3 stated observations of resident sexual behaviors and redirection instructions | |
| Memory Care Coordinator | E2 confirmed sexual behaviors were not addressed in service plans |
Inspection Report
Original Licensing
Deficiencies: 0
Date: May 4, 2025
Visit Reason
Original investigation of FRI IL 191107 for licensing compliance.
Findings
The establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
The survey was conducted to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
The document is a Plan of Correction submitted by Westminster Village in response to licensure findings related to failure to notify administration of an allegation of misappropriation of resident property during a survey conducted on March 28, 2025.
Complaint Details
The visit was complaint-related based on an allegation of misappropriation of resident property. The facility failed to notify administration timely about the allegation.
Findings
The facility failed to notify administration for three days of an allegation of misappropriation of resident property (missing money) for one resident out of three reviewed for theft. The facility responded by providing additional education to team members on the policy for Abuse and Neglect Prevention and Reporting.
Deficiencies (1)
Failure to notify administration for three days of an allegation of misappropriation of resident property (missing money) for one resident of three reviewed for theft.
Report Facts
Survey Date: Mar 28, 2025
Facility Response Date: Apr 17, 2025
Completion Date: Apr 17, 2025
Residents reviewed for theft: 3
Days failed to notify administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Netzke | Director of Assisted Living | Signed the Plan of Correction and named in the response |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of misappropriation of resident property (missing money) involving one resident.
Complaint Details
The complaint involved an allegation of theft of $700 from resident R1's purse. The facility did not notify Administration until three days after being informed of the missing money. The allegation was investigated through interviews and record review, but the missing money was not recovered and no staff were identified as responsible.
Findings
The facility failed to notify Administration within three days of the allegation of missing $700 from a resident's purse. Interviews and record reviews confirmed the delay in reporting and that staff were unaware of the missing money during the relevant time frame.
Deficiencies (1)
Failure to notify Administration within three days of an allegation of misappropriation of resident property (missing money) for one resident.
Report Facts
Amount of missing money: 700
Days delayed in notification: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director | Interviewed regarding the allegation and notification delay |
| E3 | Campus Director of Nursing | Verified staff notification procedures |
| E9 | Receptionist | Notified by resident's daughter about missing money and sent email notification |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 22, 2025
Visit Reason
Annual Licensure survey and original investigation of FRI IL 183762 were conducted to assess compliance with service plan regulations.
Findings
The facility failed to revise service plans as needed for two of six sampled residents, specifically not addressing a venous ulcer for resident R4 and not updating fall risk interventions for resident R1 after multiple falls.
Deficiencies (2)
Failed to revise the service plan to address a venous ulcer on resident R4's right lower leg.
Failed to revise the service plan for resident R1 after falls to implement interventions to reduce fall risk.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director | Confirmed that R4's venous ulcer was never addressed on the service plan. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
The document is a Plan of Correction responding to an Annual Licensure survey conducted on January 21-22, 2025, addressing deficiencies found during the survey.
Findings
The surveyor alleged that the facility failed to revise the service plan as needed for two of six sampled residents following significant changes in their physical, cognitive, or functional condition.
Deficiencies (1)
Failure to revise the service plan as needed for two of six sampled residents after significant changes in condition.
Report Facts
Survey Dates: Survey conducted from 2025-01-21 to 2025-01-22
Facility Response Date: Facility response date is 2025-02-07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Netzke | Director of Assisted Living | Named in facility comments and signature on Plan of Correction |
Report
Apr 10, 2024
Report
Mar 26, 2024
Report
Jun 23, 2023
Report
Jun 7, 2023
Report
Oct 14, 2022
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