Inspection Reports for Westminster Village Muncie
5801 W Bethel Ave, Muncie, IN 47304, IN, 47304
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 17, 2024, was a complaint investigation that found no deficiencies related to the allegations. Prior inspections showed a mixed pattern, with several citations related mainly to Life Safety Code issues such as obstructed egress routes, door functionality, and oxygen storage ventilation, as well as deficiencies in medication storage, vaccination protocols, and staff certification. Complaint investigations were mostly unsubstantiated, except for one in March 2024 where the facility was cited for inadequate staff training on elopement policy after a resident was unsupervised outdoors briefly. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections indicate some improvement in Life Safety compliance, though medication management and staff training issues have appeared intermittently.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
254 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 254
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448553.
Complaint Details
Complaint IN00448553 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00448553 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 55
Census Residential beds: 199
Total Census: 254
Census Payor Medicare: 15
Census Payor Medicaid: 5
Census Payor Other: 35
Total Census Payor: 55
Inspection Report
Re-Inspection
Census: 57
Capacity: 76
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/11/24 was performed to verify compliance with prior deficiencies.
Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 76
Census: 57
Inspection Report
Life Safety
Census: 57
Capacity: 76
Deficiencies: 3
Date: Jun 11, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey found the facility not in compliance due to obstructions in means of egress, an exit door requiring heavy force to open, and non-functioning mechanical ventilation in the oxygen storage room.
Deficiencies (3)
Means of egress were obstructed by three residents sitting in reclining wheelchairs and one resident sleeping in a recliner blocking the corridor, impeding instant use in case of emergency.
One exit door to the outside on the Bristol wing nearest to resident room #25 required heavy force to open.
Oxygen storage room ventilation was not working properly due to a broken belt on the vent motor.
Report Facts
Facility capacity: 76
Census: 57
Residents affected by egress obstruction: 10
Staff affected by egress obstruction: 4
Visitors affected by egress obstruction: 2
Residents affected by exit door issue: 12
Staff affected by exit door issue: 4
Visitors affected by exit door issue: 2
Oxygen tanks in storage room: 24
Residents affected by oxygen room ventilation issue: 14
Staff affected by oxygen room ventilation issue: 4
Visitors affected by oxygen room ventilation issue: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Crutcher | President and Administrator | Named in relation to the Plan of Correction and exit conference |
| Physical Plant Manager | Interviewed and acknowledged findings related to egress obstruction, exit door, and oxygen room ventilation | |
| Assistant Physical Plant Manager | Participated in observations and exit conference | |
| Executive Director/Administrator | Participated in exit conference | |
| Executive Assistant | Participated in exit conference |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 28, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Westminster Village Muncie was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 195
Capacity: 195
Deficiencies: 3
Date: May 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from May 21 to May 28, 2024.
Findings
The facility was found deficient in secure storage and labeling of drugs and biologicals, failure to offer appropriate pneumococcal vaccinations to eligible residents, and inadequate 24-hour coverage of staff certified in first aid and CPR.
Deficiencies (3)
Failed to provide safe and secure storage of medications for 17 of 17 residents on the Bristol Unit and failed to label a multi-use medication vial with an open date for 1 of 4 residents reviewed for medication storage.
Failed to implement pneumococcal vaccine policy according to CDC guidelines and failed to offer appropriate pneumococcal vaccinations for 1 of 5 residents reviewed.
Failed to ensure 24 hour coverage of a staff member with first aid and CPR certification.
Report Facts
Census Bed Type: 195
SNF/NF Census: 56
Residential Census: 139
Medicare Census: 11
Medicaid Census: 5
Private Pay Census: 40
Hours missing First Aid coverage: 3
Hours missing First Aid coverage: 5
Hours missing First Aid coverage: 1.5
Hours missing First Aid coverage: 3
Hours missing First Aid coverage: 9
Hours missing First Aid coverage: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Crutcher | HFA, President and Administrator | Signed Plan of Correction and facility representative |
| RN 5 | Confirmed medication cart was unlocked during observation | |
| QMA 6 | Observed medication administration and noted unlabeled eye drop vial | |
| RN 3 | Interviewed regarding vaccination procedures and registry use | |
| LPN 4 | Interviewed regarding staff certifications for First Aid |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00428793 completed on March 6, 2024.
Complaint Details
Investigation of Complaint IN00428793 completed on March 6, 2024; facility found in compliance.
Findings
Westminster Village Muncie, Inc. was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428784 and IN00428793. Complaint IN00428784 had no deficiencies related to the allegations, while complaint IN00428793 resulted in federal/state deficiencies cited at F726.
Complaint Details
Complaint IN00428784 - No deficiencies related to the allegations are cited. Complaint IN00428793 - Federal/state deficiencies related to the allegations are cited at F726.
Findings
The facility failed to ensure employees were trained and knowledgeable of the elopement policy and protocol, resulting in a cognitively impaired resident being unsupervised outdoors for 17 minutes. The resident exited through door #6 but did not leave the premises or sustain injuries. The facility implemented corrective actions including staff training on the wanderguard alarm system and security system, identification of residents at risk for elopement, and routine elopement drills.
Deficiencies (1)
Facility failed to ensure employees were trained in and knowledgeable of the facility elopement policy and protocol, resulting in a cognitively impaired resident being unsupervised outdoors for 17 minutes.
Report Facts
Census: 59
Total Capacity: 59
Time unsupervised: 17
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Huser | Health Operations Administrator | Signed the report |
| QMA 16 | Employee involved in the incident of resident elopement and lack of knowledge of elopement protocol | |
| RN 7 | Registered Nurse | Interviewed regarding the incident and wanderguard system |
| CNA 21 | Certified Nursing Assistant | Interviewed about wanderguard system knowledge |
| Housekeeper 18 | Interviewed about elopement protocol knowledge | |
| Unit Manager | Interviewed QMA 16 and involved in incident response | |
| Administrator 2 | Participated in video review and interview | |
| DON | Director of Nursing | Participated in video review and interview |
| Maintenance Director | Participated in video review and interview |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424477.
Complaint Details
Complaint IN00424477 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of the complaint were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 10
Medicaid census: 4
Other payor census: 43
Inspection Report
Complaint Investigation
Census: 58
Capacity: 191
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421990.
Complaint Details
Complaint IN00421990 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00421990 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 58
Census Residential: 133
Total Capacity: 191
Census Payor Type Medicare: 15
Census Payor Type Medicaid: 3
Census Payor Type Other: 40
Total Census Payor Type: 58
Inspection Report
Complaint Investigation
Census: 192
Deficiencies: 0
Date: Jul 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413618.
Complaint Details
Investigation of Complaint IN00413618 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in Complaint IN00413618 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 57
Census Residential: 135
Total Census: 192
Census Payor Medicare: 11
Census Payor Medicaid: 2
Census Payor Other: 44
Census Payor Total: 57
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Westminster Village Muncie, Inc. was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 58
Capacity: 76
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/20/23 by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code Survey, Westminster Village Muncie, Inc was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Life Safety
Census: 62
Capacity: 76
Deficiencies: 5
Date: Feb 20, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, including corridor obstructions, door latching issues, expired inspection certificates for boilers and water heaters, improper use of extension cords, and improper storage of oxygen cylinders.
Deficiencies (5)
Failed to ensure 1 of 1 corridor means of egress was continuously maintained free of obstructions due to Personal Protective Equipment (PPE) carts without wheels obstructing the corridor near resident rooms 53 and 55.
Failed to ensure 1 of 1 resident room corridor doors was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke (door to resident room 56).
Failed to ensure 2 of 2 fuel fired water heaters and 2 of 2 boilers had current inspection certificates to ensure safe operating condition.
Failed to ensure 20 of 20 flexible cords were not used as a substitute for fixed wiring; extension cords were used to power display cabinets in corridors.
Failed to ensure empty oxygen cylinders were segregated from full cylinders and marked to avoid confusion; empty cylinders were intermixed with full cylinders in the oxygen storage room.
Report Facts
Deficiencies cited: 5
Facility capacity: 76
Census: 62
Number of doors checked: 80
Number of flexible cords observed: 20
Number of boilers and water heaters inspected: 4
Number of oxygen cylinders affected: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Crutcher | President/Administrator | Named in relation to findings and exit conference |
| Physical Plant Director | Interviewed regarding multiple deficiencies including corridor obstructions, door latching, expired inspections, extension cords, and oxygen cylinder storage | |
| Maintenance Director | Interviewed regarding door latching deficiency |
Inspection Report
Annual Inspection
Census: 137
Capacity: 194
Deficiencies: 3
Date: Feb 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from February 6 to 10, 2023.
Findings
The facility was found to have deficiencies related to baseline care plans, quality of care including failure to obtain daily weights and notify physicians, and failure to ensure fall prevention interventions were in place for residents at risk of falls. The facility submitted plans of correction and was found in compliance with State Residential Licensure Survey requirements.
Deficiencies (3)
Failed to complete a baseline care plan within 48 hours for 1 of 1 residents reviewed for accidents (Resident 13).
Failed to obtain daily weights per physician's order and failed to notify physician of weight gain for residents with edema (Residents 15, 52, and 157).
Failed to ensure residents at risk for falls had interventions in place in accordance with their care plan for 4 of 8 residents reviewed (Residents 16, 38, 41, and 42).
Report Facts
Survey dates: 5
Census Bed Type - SNF/NF: 57
Census Bed Type - Residential: 137
Total Capacity: 194
Residents reviewed for edema: 3
Residents reviewed for fall prevention: 8
Residents with fall prevention deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jo Crutcher | HFA, President and Administrator | Signed report and plan of correction |
| Unit Manager | Interviewed regarding baseline care plan and weight notification deficiencies | |
| Assistant Director of Nursing (ADON) | Provided facility policies and interviewed regarding deficiencies and corrective actions | |
| Health Operations Administrator | Interviewed regarding fall prevention device deficiencies |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391452.
Complaint Details
Complaint IN00391452 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00391452 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint.
Report Facts
Census Bed Type - SNF: 59
Census Bed Type - Residential: 126
Total Census: 185
Census Payor Type - Medicare: 16
Census Payor Type - Other: 43
Total Census Payor: 59
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