Westminster Village: Resident Attacked in Bed by Wandering Roommate - IL
All of it happened at Westminster Village, a nursing facility in Bloomington. All of it involved the same resident. And staff at every level of the facility, from floor nurses to the Director of Nurses, confirmed they had known for some time that this was coming.
The attack happened on May 20, 2026, at approximately 7:45 in the evening. The resident identified in the inspection report as R9, a man described in his own records as cognitively intact, was in his room when R8 walked in uninvited. R9 told R8 to turn around and leave. R8 began hitting him instead. R9 threw his arms up to block the blows. R8 grabbed him by the wrists. R9 started yelling for V5, an LPN working the floor, and kept yelling until she came.
V5 entered the room and managed to get R8 to release R9's wrists and return to his own room. R9 told inspectors he did not feel safe after that. He also told them he didn't think he should have to be the one to move, since he was the victim. Staff told him R8 would be placed on one-on-one monitoring going forward, and R9 said that made him feel somewhat better. He considered calling the police. He didn't.
What R9 also told inspectors, speaking six days after the attack, was that R8 had walked into his room uninvited on multiple occasions before that night. The physical assault on May 20 was the first time R8 had become violent with him. It was not, in any sense, the first warning.
The Director of Nurses, identified as V2, told inspectors on May 27 that R8 has a history of wandering into other residents' rooms. She said staff had been conducting checks every 15 minutes before the incident. She acknowledged those checks were not enough. Since the attack, she said, staff were supposed to provide constant supervision. Then she added that sometimes there are call-offs, or staff simply don't have enough people to provide constant supervision.
That admission sits at the center of what inspectors found. The facility knew R8 wandered. The facility knew he entered other residents' rooms. The facility's own response to the attack, constant supervision, was something the Director of Nurses described as inconsistently achievable on any given shift.
V4, an RN, told inspectors on May 27 that R8 is very confused and wanders often into other residents' rooms. V5, the same LPN who had intervened during the attack, confirmed R8 has a history of wandering into other residents' rooms. V7, another LPN, said R8 wanders a lot and described an incident from the previous week in which R8 had wandered into a female resident's room and she had to call for staff to come help her. V8, a fourth LPN, put it plainly: R8 wanders all of the time, she said, and he is very hard to keep out of other residents' rooms because he moves quickly.
Four nurses. Four separate interviews. Four versions of the same answer.
The residents who spoke to inspectors described a pattern that had been going on long enough for them to have developed their own individual strategies for handling it. R47 said R8 had come into her room on two separate occasions. She told him to leave both times. He took his time about it. She got up, walked him to the door herself, and closed it behind him. She told inspectors she does not want to have to deal with that anymore.
R33 said R8 wandered into her room uninvited and was standing by her bathroom door when she told him to get out. He eventually turned around and left on his own.
R28 said R8 came to her doorway, but staff came up behind him quickly and redirected him before he got further inside.
R13's account was the one that stayed. She was asleep when R8 entered her room. When she woke up, he was standing at the foot of her bed. She didn't know who he was. She told inspectors it scared her half to death. She said she wished the facility would do something about it and supervise him better, because it creates an uneasy environment and she feels like she can't rest peacefully. The day before she spoke to inspectors, R8 had tried to come into her room again. Staff happened to already be in her room and told him to leave.
Happened to already be there. That is the distinction the inspection record keeps returning to, the difference between what the facility knew and what it actually put in place to act on that knowledge. Fifteen-minute checks for a man described by four nurses as fast-moving, hard to contain, and constantly wandering. A plan for constant supervision that the Director of Nurses acknowledged the facility couldn't always staff.
The inspection was triggered by a complaint and conducted on May 29, 2026. CMS classified the harm level as minimal harm or potential for actual harm. R9, the man who was grabbed by the wrists and struck in his own bed, might assess that classification differently. He told inspectors he did not feel safe. He told them staff did not do a good job supervising R8. He said he thought about calling the police.
He was still living in the same facility when inspectors arrived, nine days after the attack, in the room he had refused to leave because he was the one who had done nothing wrong.
R13 was still there too, trying to sleep, hoping the staff would be in her room the next time R8 came down the hall.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Village from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
WESTMINSTER VILLAGE in BLOOMINGTON, IL was cited for violations during a health inspection on May 29, 2026.
All of it happened at Westminster Village, a nursing facility in Bloomington.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.