Inspection Report Summary
The most recent inspection on April 30, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a mixed pattern, with several citations related mainly to care planning, medication administration, emergency preparedness, and fire safety issues. Prior reports noted deficiencies in resident care planning for pain and behavior management, medication administration errors, and emergency preparedness including fire safety system maintenance. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved failure to notify family members and inadequate catheter care leading to hospitalization. The facility appears to have addressed many prior issues, with recent inspections showing compliance and improvement in areas previously cited.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
376% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 19, 2025
Visit Reason
The inspection was conducted due to complaints related to resident safety, medication administration, and infection control at Westminster Village North nursing home.
Findings
The facility failed to provide adequate supervision to prevent a cognitively impaired resident from leaving a secured memory unit unsupervised, delayed administration of a newly ordered medication, and failed to ensure proper use of personal protective equipment during wound care.
Complaint Details
The complaint investigation revealed that Resident B, a cognitively impaired resident, eloped from the secured memory care unit due to inadequate supervision and door security. Resident E experienced delayed medication administration and improper wound care practices, including failure to wear gowns and perform hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure adequate supervision to prevent a cognitively impaired resident from leaving a secured memory unit unsupervised. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a newly ordered medication was received timely from the contracted pharmacy and administered as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure personal protective equipment was worn during wound treatment and hand hygiene was performed after doffing gloves. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dementia care: 3
Residents reviewed for unnecessary medications: 3
Elopement risk score: 5
Medication dose delay: 2
Medication delivery time: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 2 | RN | Observed Resident B outside the secured memory care unit and provided wound care to Resident E without proper PPE. |
| Director of Nursing | DON | Provided information about medication delivery, incident report, and facility policies. |
| Licensed Practical Nurse 3 | LPN | Observed exit doors of the secured memory unit and demonstrated door operation. |
| Certified Nurse Aide 4 | CNA | Found Resident B sitting outside on a bench and returned her to the secured memory care unit. |
| Executive Director | ED | Provided the incident report and investigation file related to Resident B's elopement. |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 198
Deficiencies: 0
Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of three complaints: IN00458527, IN00458303, and IN00457759.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaints IN00458527, IN00458303, and IN00457759 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 123
Census Bed Type - Residential: 75
Census Bed Type - Total: 198
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 38
Census Payor Type - Total: 123
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 10, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00446258 and IN00447945 completed on December 16, 2024.
Findings
Westminster Village North 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 to the Complaint Investigation. Both complaints IN00446258 and IN00447945 were corrected.
Complaint Details
Complaint IN00446258 and Complaint IN00447945 were investigated and found corrected.
Report Facts
Complaint Investigation Completion Date: Dec 16, 2024
Inspection Report
Complaint Investigation
Census: 139
Capacity: 222
Deficiencies: 0
Jan 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449554.
Findings
No deficiencies related to the allegations in Complaint IN00449554 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00449554 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 139
Census Residential: 83
Total Capacity: 222
Census Payor Type Medicare: 13
Census Payor Type Medicaid: 62
Census Payor Type Other: 64
Inspection Report
Complaint Investigation
Census: 128
Capacity: 128
Deficiencies: 3
Dec 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00446258 and IN00447945 related to federal/state deficiencies.
Findings
The facility failed to ensure Minimum Data Set (MDS) assessment accuracy for behaviors, failed to provide appropriate care planning and interventions for a resident with dementia and behaviors, and failed to administer narcotic pain medication per physician orders for one resident.
Complaint Details
Complaint IN00446258 related to medication administration deficiencies. Complaint IN00447945 related to treatment/service for dementia and behavior management deficiencies.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) assessment accuracy for behaviors for 1 of 3 residents reviewed for behavior management (Resident B). | SS=D |
| Failed to ensure a resident with dementia and behaviors was care planned for behaviors with resident specific interventions, ensure visits by mental health provider, and document approaches to care for 1 of 3 residents reviewed for behavior management (Resident B). | SS=D |
| Failed to ensure a narcotic pain medication was administered per physician orders for 1 of 3 residents reviewed for pain management (Resident B). | SS=D |
Report Facts
Census: 128
Total Capacity: 128
Medicare Census: 15
Medicaid Census: 76
Other Payor Census: 37
Days Behaviors Exhibited in September 2024: 24
Days Behaviors Exhibited in October 2024: 23
Days Behaviors Exhibited in November 2024: 25
Days Behaviors Exhibited in December 2024: 11
Fentanyl Patch Dosage Error: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse 4 | Interviewed regarding Resident B's verbal and physical aggression and staff attempts to manage behaviors. | |
| Director of Nursing | DON | Interviewed regarding medication administration and behavior management documentation. |
| Former Social Services Director | Interviewed regarding behavior management program inadequacies. | |
| MDS Coordinator | Interviewed regarding responsibility for completing MDS behavior section and accuracy. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 16, 2024
Visit Reason
The inspection was conducted based on complaints related to behavior management, dementia care, and pain management for Resident B at Westminster Village North.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for behaviors, did not provide appropriate care planning and interventions for a resident with dementia and behaviors, and failed to administer narcotic pain medication according to physician orders for Resident B. The facility's behavior management program was inadequate, lacking resident-specific non-pharmacological interventions and proper documentation of approaches to behaviors.
Complaint Details
This citation relates to Complaint IN00447945 for behavior management and dementia care, and Complaint IN00446258 for medication administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) assessment accuracy for behaviors for 1 of 3 residents reviewed for behavior management (Resident B). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with dementia and behaviors was care planned for behaviors with resident specific interventions, mental health visits, and documentation of approaches to care (Resident B). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a narcotic pain medication was administered per physician orders for 1 of 3 residents reviewed for pain management (Resident B). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days with behaviors exhibited: 24
Days with behaviors exhibited: 23
Days with behaviors exhibited: 25
Days with behaviors exhibited: 11
Fentanyl patch dose: 12
Fentanyl patch dose: 25
Incorrect fentanyl dose administered: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse 4 | Interviewed regarding Resident B's verbal and physical aggression and staff attempts to redirect | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding charting and medication administration for Resident B |
| Social Services Director | Former Social Services Director | Interviewed regarding behavior management program inadequacies |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Oct 15, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00439975, IN00440139, IN00444191, IN00445069, and IN00445085) at Westminster Village North.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B.
Complaint Details
Investigation of complaints IN00439975, IN00440139, IN00444191, IN00445069, and IN00445085 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 119
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 40
Inspection Report
Follow-Up
Census: 123
Capacity: 148
Deficiencies: 0
Oct 10, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/14/2024.
Findings
At this PSR survey, Westminster Village North was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 148
Census: 123
Inspection Report
Routine
Census: 111
Capacity: 148
Deficiencies: 11
Aug 14, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness requirements due to failure to conduct required emergency plan exercises and drills. Life Safety Code deficiencies included fire door latching issues, missing semiannual inspections for kitchen exhaust systems, fire alarm system inspection documentation gaps, sprinkler system testing deficiencies, fire damper inspection documentation gaps, electrical panel access obstructions, missing electrical receptacle testing documentation, generator testing and fuel quality documentation gaps, and improper use of power strips and extension cords in resident rooms.
Severity Breakdown
SS=F: 6
SS=E: 4
SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills. | SS=F |
| Failed to maintain 2-hour fire rated separation between skilled nursing unit and independent living due to corridor door latching mechanisms being dogged down. | SS=E |
| Failed to ensure semiannual inspection of kitchen exhaust systems; documentation for inspections prior to 06/04/24 unavailable. | SS=D |
| Failed to maintain fire alarm system with required semiannual visual inspections; documentation missing for six months after 10/11/23. | SS=F |
| Failed to maintain sprinkler system with required 10-year testing of dry sprinklers; documentation of testing not available. | SS=E |
| One corridor door to resident sleeping room in Aspen Commons did not latch properly and would not resist passage of smoke. | SS=E |
| Failed to ensure all fire dampers were inspected and tested within the most recent four-year period; three fire dampers in attic lacked inspection stickers. | SS=F |
| Failed to maintain clear and unobstructed working space in electrical panel room; three trash bins stored within required working space. | SS=E |
| Failed to maintain documentation of electrical receptacle testing in resident rooms within the last 12 months. | SS=F |
| Failed to exercise three emergency generators monthly for 30 minutes in July 2024; missing documentation of annual fuel quality testing and 36-month load testing. | SS=F |
| Used extension cords and power strips as substitutes for fixed wiring in resident rooms, including patient care vicinities. | SS=E |
Report Facts
Certified beds: 148
Census: 111
Deficiencies cited: 11
Inspection Report
Recertification
Census: 72
Deficiencies: 15
Jul 18, 2024
Visit Reason
This visit was for a State Residential Licensure Survey and included a Recertification and State Licensure Survey with investigation of multiple complaints.
Findings
The facility was found in compliance with state licensure requirements but had deficiencies related to resident dignity and respect, reasonable accommodations, resident/family group grievances, notification of changes, quality of care, accident prevention, respiratory care, pain management, dialysis care, medication labeling and storage, food quality and safety, infection control, and pest control.
Complaint Details
Complaint IN00437695 - No deficiencies related to the allegations are cited. Complaint IN00437923 - Federal/state deficiencies related to the allegations are cited at F580, F684, F689, and F697. Complaint IN00431844 - Federal/state deficiencies related to the allegations are cited at F689. Complaint IN00430036 - Federal/state deficiencies related to the allegations are cited at F585 and F609.
Severity Breakdown
SS=E: 7
SS=D: 7
Deficiencies (15)
| Description | Severity |
|---|---|
| Residents expressed concerns about not being treated with dignity and respect, including delays in care and staff responses. | SS=E |
| Resident D had a wheelchair that was not the correct size for his function and comfort, causing discomfort and difficulty with feeding. | SS=D |
| Facility failed to promptly act on resident council grievance about removal of tablecloths in the dining room. | SS=E |
| Resident F's family was not notified of a fall event as required. | SS=D |
| Facility failed to timely notify resident representative of a fall event for Resident F. | SS=D |
| Facility failed to ensure vital signs were obtained prior to administering medication with parameters, follow up on urinalysis, and ensure residents attended neurology appointments. | SS=D |
| Facility failed to ensure incident reports were completed after each fall event, post fall assessments were completed every shift for 72 hours, and fall interventions were in place. | SS=E |
| Resident C on continuous oxygen therapy had no physician order in the electronic health record and humidification container was not changed timely. | SS=D |
| Facility failed to administer a pain-relieving patch as ordered for Resident K. | SS=D |
| Facility failed to ensure pre and post dialysis assessments were conducted for Resident 176 on dialysis days. | SS=D |
| Facility failed to ensure medications stored in medication carts were not expired; an expired insulin vial was found in use. | SS=D |
| Facility failed to provide residents with palatable grilled cheese sandwiches as ordered. | SS=D |
| Facility failed to maintain a clean, sanitized, and well-maintained kitchen including failure to wear beard restraints, maintain dishwasher temperature, sanitize rolling carts, and properly store food products. | SS=E |
| Facility failed to maintain infection control practices during medication administration including picking up dropped pills with bare hands and not cleaning blood pressure device between residents. | SS=D |
| Facility failed to maintain an effective pest control program resulting in flying insects in a food storage area. | SS=E |
Report Facts
Survey dates: 7
Census: 72
Deficiency counts: 14
Residents affected: 123
Insulin vial expiration days: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Ward | Executive Director | Signed the report |
| LPN 3 | Licensed Practical Nurse | Involved in medication administration and fall event observations |
| RN 3 | Registered Nurse | Observed using blood pressure device without cleaning between residents |
| RN 25 | Registered Nurse | Involved in scheduling and communication regarding neurology appointment for Resident F |
| QMA 2 | Qualified Medication Aide | Observed picking up dropped pills with bare hands during medication administration |
| DON | Director of Nursing | Provided multiple interviews and policies related to falls, grievances, and infection control |
| ADON | Assistant Director of Nursing | Provided interviews and policies related to dialysis and oxygen care |
| SSA | Social Services Assistant | Involved in grievance documentation and follow-up |
| TM | Therapy Manager | Provided information on fall discussions and wheelchair needs |
| KM 2 | Kitchen Manager | Provided information on kitchen sanitation and pest control |
| DSD | Dining Service Director | Provided information on kitchen sanitation and dishwasher issues |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 18, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey, including paper compliance to the Investigation of Complaints IN00437923, IN00431844, and IN00430036 completed on July 18, 2024.
Findings
Westminster Village North 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 to the Annual Recertification and State Licensure Survey and Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 6
Jul 18, 2024
Visit Reason
The inspection was conducted based on complaints related to failure to notify resident representatives of falls, failure to timely address resident grievances, failure to timely report suspected abuse, failure to provide appropriate treatment and care, failure to ensure safe environment and supervision to prevent accidents, and failure to provide appropriate pain management.
Findings
The facility failed to notify a resident's representative of a fall event, failed to timely address resident grievances including lack of documentation and follow-up, failed to timely report suspected abuse to the state health department, failed to ensure residents attended scheduled neurology appointments, failed to conduct post-fall assessments every shift for three days, failed to implement fall interventions, and failed to administer a pain-relieving patch as ordered.
Complaint Details
Complaint IN00437923 relates to failure to notify resident representative of fall, failure to ensure neurology appointments, failure to administer pain medication as ordered, and failure to conduct post fall assessments. Complaint IN00430036 relates to failure to timely address grievances and failure to timely report suspected abuse. Complaint IN00431844 relates to fall prevention and management.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to notify a resident's representative of a fall event for 1 of 8 residents reviewed for accidents (Resident F). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely address resident grievances, provide dates of resolution, follow-up, confirmation status, and means for anonymous filing for 7 of 7 grievances reviewed (Residents N, P, and R). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse or neglect to the Indiana Department of Health for 1 of 2 residents investigated for dignity (Resident N). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure vital signs were obtained prior to administering medication with blood pressure parameters, failed to follow up on urinalysis orders, and failed to ensure residents attended neurology appointments for 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure incident reports were completed after each fall event, post fall assessments were completed every shift for 72 hours, and fall interventions were in place for 5 of 8 residents reviewed for accidents (Residents E, C, F, M, and D). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer a pain-relieving lidocaine patch as ordered for 1 of 4 residents reviewed for pain (Resident K). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 6
Post fall assessments: 3
Lidocaine patch application time: 12
Medication dosage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 25 | Registered Nurse | Named in failure to schedule neurology appointment and communication with resident representative |
| LPN 3 | Licensed Practical Nurse | Named in failure to notify resident representative of fall |
| LPN 11 | Licensed Practical Nurse | Named in grievance related to medication administration and rude behavior |
| Director of Nursing | Director of Nursing | Interviewed regarding fall assessments, grievance follow-up, and abuse reporting |
| Social Services Director | Social Services Director | Provided grievance investigation and follow-up forms |
| Assistant Director of Nursing | Assistant Director of Nursing | Investigated grievances and medication administration issues |
| RN 6 | Registered Nurse | Named in failure to apply pain patch as scheduled |
Inspection Report
Complaint Investigation
Deficiencies: 16
Jul 18, 2024
Visit Reason
The inspection was conducted based on complaints and concerns related to resident dignity, care, grievance handling, fall management, medication administration, respiratory care, food quality, kitchen sanitation, and pest control at Westminster Village North nursing home.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to timely provide appropriate wheelchairs, failure to notify representatives of falls, failure to address resident grievances promptly and properly, failure to report alleged abuse to the state, failure to ensure residents attended medical appointments, failure to conduct proper post-fall assessments and interventions, failure to maintain clean and safe kitchen and food storage areas, failure to properly administer medications and maintain infection control during medication administration, and failure to maintain an effective pest control program.
Complaint Details
This inspection relates to multiple complaints including IN00437923, IN00430036, and IN00431844. Complaints involved dignity and respect, grievance handling, fall management, medication administration, respiratory care, food quality, kitchen sanitation, and pest control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to assure residents were treated with dignity and respect. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely provide a resident with a wheelchair that accommodated his height. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to promptly act on a resident council grievance about tablecloths in the dining room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify a resident's representative of a fall event. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely address resident grievances, provide dates of resolution and follow-up, and allow anonymous filing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse or neglect to the Indiana Department of Health. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents attended scheduled neurology appointments and arranged transportation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure vital signs were obtained prior to administering medication with parameters to hold, failed to follow up on urinalysis orders, and failed to ensure residents attended medical appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure incident reports were completed after each fall, post fall assessments were completed every shift for 72 hours, and fall interventions were in place. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident on continuous oxygen therapy had a physician's order in the electronic health record and failed to change the humidification container as per policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer a pain-relieving patch as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pre and post dialysis assessments were conducted. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications stored in medication carts were not expired. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a clean, sanitized, and well maintained kitchen including failure to wear beard restraints, proper food storage, dishwasher temperature, and sanitizing rolling carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control practices during medication administration including picking up dropped pills with bare hands and not cleaning blood pressure device between residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program to prevent flying insects in a food storage area. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 9
Residents affected: 1
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts observed: 6
Dirty rolling carts observed: 5
Dirty plates observed: 3
Flying insects observed: 9
Residents attending resident council: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 25 | Registered Nurse | Involved in scheduling neurology appointment for Resident F |
| LPN 3 | Licensed Practical Nurse | Observed Resident F sitting on floor after fall and medication administration |
| LPN 11 | Licensed Practical Nurse | Involved in grievances filed by Resident P regarding medication administration and behavior |
| DON | Director of Nursing | Provided policies, interviews, and oversight of grievance and fall management |
| ADM | Administrator | Provided policies, interviews, and oversight of grievance reporting and wheelchair procurement |
| SSA | Social Services Assistant | Involved in grievance documentation and resident interviews |
| SSD | Social Services Director | Provided grievance investigation forms and interviews |
| TM | Therapy Manager | Interviewed regarding wheelchair procurement and fall discussions |
| QMA 2 | Qualified Medication Aide | Observed picking up dropped pills with bare hands during medication administration |
| RN 3 | Registered Nurse | Observed not disinfecting blood pressure device between residents |
| LPN 9 | Licensed Practical Nurse | Interviewed regarding oxygen order and care for Resident C |
| KM 2 | Kitchen Manager | Interviewed regarding kitchen sanitation and pest control |
| DSD | Dining Service Director | Interviewed regarding kitchen sanitation and dishwasher temperature |
| RN 6 | Registered Nurse | Interviewed regarding pain patch administration for Resident K |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2024
Visit Reason
Paper compliance review to the Complaint Investigation completed on February 23, 2024.
Findings
Westminster Village North 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 to the Complaint Investigation.
Complaint Details
The visit was related to a complaint investigation with paper compliance reviewed and found in compliance.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 2
Feb 23, 2024
Visit Reason
This visit was for the investigation of complaints IN00423770 and IN00428586. Complaint IN00423770 had no deficiencies related to the allegations, while Complaint IN00428586 resulted in federal/state deficiencies cited.
Findings
The facility failed to timely notify a cognitively impaired resident's Power of Attorney of a new medication order and failed to accurately monitor urinary output and urine characteristics for a resident with an indwelling urinary catheter, resulting in hospitalization for acute urinary tract infection and urinary obstruction.
Complaint Details
Complaint IN00423770 had no deficiencies related to the allegations. Complaint IN00428586 had federal/state deficiencies cited at F0580 and F0690 related to failure to notify family of medication changes and failure to monitor catheter care leading to hospitalization.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely notify a cognitively impaired resident's POA of a new medication order. | SS=D |
| Failed to accurately monitor urinary output and urine characteristics for a resident with an indwelling urinary catheter resulting in hospitalization for acute urinary tract infection and urinary obstruction. | SS=D |
Report Facts
Census: 122
Total Capacity: 122
Medication doses: 3
Urine output volumes (ml): 500
Urine output volumes (ml): 350
Intake and output volumes (ml): 1400
Intake and output volumes (ml): 1100
Bladder scan volume (ml): 919
White Blood Cell count: 22.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Harris | Administrator | Signed Plan of Correction letter |
| Brenda Buroker | Director of Long Term Care | Recipient of Plan of Correction letter |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 23, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00428586) regarding the facility's failure to timely notify a cognitively impaired resident's Power of Attorney about a new medication order and failure to provide appropriate catheter care resulting in hospitalization.
Findings
The facility failed to timely notify Resident B's Power of Attorney of a new medication order for Lorazepam and failed to accurately monitor urinary output and urine characteristics for Resident B, who had an indwelling urinary catheter, resulting in hospitalization for acute urinary tract infection and urinary obstruction.
Complaint Details
This Federal tag relates to Complaint IN00428586. The complaint involved failure to notify the resident's family or Power of Attorney about a new medication order and failure to provide appropriate catheter care leading to hospitalization.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely notify a cognitively impaired resident's Power of Attorney of a new medication order for Lorazepam. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately monitor urinary output and urine characteristics for a resident with an indwelling urinary catheter resulting in hospitalization for acute urinary tract infection and urinary obstruction. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication doses: 3
Urine output volumes: 500
Urine output volumes: 350
Urine output volumes: 400
Urine output volumes: 700
Urine output volumes: 100
Urine output volumes: 1500
Urine output volumes: 850
White Blood Cell count: 22.1
Bladder scan volume: 919
Leg bag urine volume: 500
Inspection Report
Complaint Investigation
Census: 120
Capacity: 193
Deficiencies: 0
Nov 29, 2023
Visit Reason
This visit was conducted for the investigation of multiple nursing home complaints (IN00409155, IN00409211, IN00409740, IN00418899) and a residential complaint (IN00405630).
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00409155, IN00409211, IN00409740, IN00418899, and IN00405630 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 120
Census Residential: 73
Total Capacity: 193
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 73
Census Payor Type Other: 41
Total Census Payor: 120
Inspection Report
Life Safety
Census: 126
Capacity: 148
Deficiencies: 0
Jun 1, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Westminster Village North was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered with a fire alarm system including smoke detection in corridors and resident sleeping rooms.
Report Facts
Facility capacity: 148
Census: 126
Inspection Report
Renewal
Deficiencies: 0
May 5, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification, State Licensure, and State Residential Licensure completed on March 24, 2023.
Findings
Westminster Village North 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 for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 123
Capacity: 148
Deficiencies: 3
Apr 11, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including obstructed means of egress due to stored totes in a corridor, fire alarm systems not maintained with correct date/time, and a therapy corridor door with a doorstop preventing proper closing and smoke resistance.
Severity Breakdown
SS=E: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to maintain means of egress free from obstructions in 1 of 7 corridors due to storage of six 10-gallon plastic totes in the hallway. | SS=E |
| Facility failed to ensure 1 of 1 fire alarm systems was continuously maintained in proper operating condition; fire alarm panels displayed incorrect date and time. | SS=C |
| Facility failed to ensure 1 of 1 Physical Therapy corridor door set was provided with a means suitable for keeping the door closed, had no impediment to closing, latching, and would resist the passage of smoke due to a flip down door stop. | SS=E |
Report Facts
Certified beds: 148
Census: 123
Plastic totes stored in hallway: 6
Residents potentially affected by door deficiency: 8
Staff potentially affected by door deficiency: 4
Visitors potentially affected by door deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Harris | Administrator | Signed Plan of Correction and correspondence |
| Brenda Buroker | Director of Long Term Care | Recipient of Plan of Correction and referenced in survey correspondence |
| Director of Campus Operations | Interviewed during observations related to deficiencies | |
| Administrator-in-training | Interviewed during observations related to deficiencies |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 10
Mar 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted March 21-24, 2023.
Findings
The facility was cited for multiple deficiencies including failure to provide adequate oral care, wound care, fall prevention interventions, proper catheter care, nutrition supplementation, tube feeding management, pain management, medication storage, and timely dental follow-up.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to carry out activities of daily living (oral hygiene) for a resident unable to perform oral care as prescribed. | SS=D |
| Failed to monitor and assess wounds, provide wound care per physician orders, and timely clarify medication orders for multiple residents. | SS=E |
| Failed to recognize and address fall intervention issues for residents including improperly positioned wheelchair anti-roll back devices and call lights not within reach. | SS=D |
| Failed to assure indwelling urinary catheter bag and tubing were not touching the floor. | SS=D |
| Failed to provide ordered dietary supplement for a resident. | SS=D |
| Failed to follow appropriate tube feeding guidelines including labeling feeding bags, capping tubing, and administering feeding as ordered. | SS=D |
| Failed to assess pain location and implement non-pharmacological interventions prior to administering PRN pain medication. | SS=D |
| Failed to ensure medications were stored securely; medication cards found unsecured in narcotic log binder. | SS=D |
| Failed to timely follow up on dental recommendation for a chipped tooth. | SS=D |
| Failed to ensure electronic medication administration records were accurate regarding medication hold parameters for Digoxin. | — |
Report Facts
Survey dates: 4
Census: 73
Residents reviewed for ADLs: 3
Residents reviewed for wounds: 4
Residents reviewed for medications: 5
Residents reviewed for accidents: 2
Residents reviewed for urinary catheters: 2
Residents reviewed for nutrition: 1
Residents reviewed for tube feeding: 1
Residents reviewed for pain: 3
Residents reviewed for medication storage: 5
Residents reviewed for dental services: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Harris | Administrator | Signed Plan of Correction letter |
| Brenda Buroker | Director of Long Term Care | Addressee of Plan of Correction letter |
| Ms. Brenda Buroker | Director of Long Term Care | Named in Plan of Correction correspondence |
Inspection Report
Routine
Deficiencies: 9
Mar 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities of daily living, wound care, medication management, fall prevention, urinary catheter care, nutrition, tube feeding, pain management, medication storage, and dental services.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate oral care, inadequate wound monitoring and treatment, failure to implement fall prevention interventions, improper urinary catheter care, failure to provide ordered nutritional supplements, improper tube feeding procedures, inadequate pain management, unsecured medication storage, and delayed dental follow-up.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to carry out activities of daily living for a resident by not providing appropriate oral care as prescribed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor and assess wounds, provide wound care as ordered, and timely clarify medication orders for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to recognize and address fall intervention issues and assure fall interventions were implemented for residents at risk. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assure urinary catheter bag and tubing were not touching the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a physician-ordered nutritional supplement for a resident with significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow tube feeding guidelines including labeling feeding bags, capping tubing properly, and administering tube feeding as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess pain location and implement non-pharmacological interventions for pain management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were stored securely in locked compartments on medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely follow up on a dental recommendation for a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding oral care, wound care, medication clarification, pain management, and dental follow-up deficiencies. |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding lack of physician order for skin lesion dressing. |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding geri-sleeves usage for Resident 29. |
| CNA 9 | Certified Nursing Assistant | Interviewed and observed applying geri-sleeves to Resident 29. |
| Physical Therapy Assistant 10 | Physical Therapy Assistant | Interviewed regarding anti rollback devices on wheelchairs. |
| Maintenance Technician 12 | Maintenance Technician | Interviewed and observed anti rollback device positioning on wheelchair. |
| Unit Coordinator 3 | Unit Coordinator | Interviewed regarding call light usage and fall incident. |
| Unit Coordinator 2 | Unit Coordinator | Interviewed regarding medication cart organization and removal of discontinued medication. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding tube feeding procedures and pain management. |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Interviewed regarding urinary catheter bag positioning. |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Observed and interviewed regarding urinary catheter bag touching floor. |
| Director of Nursing | Director of Nursing | Provided medication storage and dental services policies. |
| Resident 11 | Subject of oral care deficiency. | |
| Resident 21 | Subject of wound care deficiency. | |
| Resident 29 | Subject of wound care and geri-sleeves deficiency. | |
| Resident 35 | Subject of fall prevention and nutrition deficiencies. | |
| Resident 51 | Subject of fall prevention deficiency. | |
| Resident 59 | Subject of wound care deficiency. | |
| Resident 73 | Subject of medication storage and dental services deficiencies. | |
| Resident 78 | Subject of wound care and medication clarification deficiency. | |
| Resident 88 | Subject of wound care and pain management deficiencies. | |
| Resident 12 | Subject of urinary catheter care deficiency. | |
| Resident 20 | Subject of tube feeding deficiency. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00399777 completed on January 23, 2023.
Findings
Westminster Village North 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 to the Complaint Investigation.
Complaint Details
Complaint Investigation IN00399777 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 119
Capacity: 177
Deficiencies: 4
Jan 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399777, which was substantiated with federal and state deficiencies cited.
Findings
The facility failed to develop and implement comprehensive care plans addressing residents' pain and fall interventions, failed to update fall care plans after incidents, failed to notify medical providers timely about abnormal vital signs, and failed to implement non-pharmacological pain management interventions for residents reviewed.
Complaint Details
Complaint IN00399777 was substantiated with federal and state deficiencies cited at F656, F657, F684, and F697.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop a care plan that included interventions addressing a resident's pain and to implement a resident's fall care plan intervention for 2 of 3 residents reviewed for accidents. | SS=D |
| Failed to update residents' fall care plans with identified interventions for 2 of 3 residents reviewed for accidents. | SS=D |
| Failed to notify the medical provider a resident's systolic blood pressure was less than 90 and a nutrition recommendation timely for 1 of 3 residents reviewed for falls and nutrition. | SS=D |
| Failed to develop and implement non-pharmacological interventions to address a resident's pain for 1 of 3 residents reviewed for change in condition. | SS=D |
Report Facts
Census SNF/NF: 119
Census Residential: 58
Total Capacity: 177
Systolic blood pressure readings below 90: 5
Pain scale ratings: 12
Audit frequency: 5
Corrective action completion date: Feb 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Harris | Administrator | Signed Plan of Correction letter |
| Brenda Buroker | Director of Long Term Care | Recipient of Plan of Correction letter |
| OTA 7 | Occupational Therapy Assistant | Interviewed regarding Resident H's fall and telephone placement |
| RD 2 | Registered Dietitian | Interviewed regarding nutritional assessments and recommendations |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding care plans, pain management, and notification of abnormal vitals |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 29, 2022
Visit Reason
Paper compliance review to the Complaint Investigation IN00381436 completed on June 3, 2022.
Findings
Westminster Village North 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 to the Complaint Investigation.
Complaint Details
Complaint Investigation IN00381436 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 13
Mar 4, 2020
Visit Reason
The inspection was conducted based on complaints regarding grievances, abuse investigation, activities of daily living assistance, quality of care, medication administration, dental services, infection prevention, and other regulatory compliance issues at Westminster Village North nursing home.
Findings
The facility failed to address grievances timely, thoroughly investigate abuse incidents, provide adequate assistance with activities of daily living, follow physician orders for treatments, ensure timely pain management, maintain medication safety and storage, provide timely dental services, and adhere to infection prevention protocols including proper glove use and equipment cleaning.
Complaint Details
The complaint investigation included grievances about missing resident property, abuse incident investigation, failure to provide adequate assistance with activities of daily living, medication errors, delayed pain management, dental care coordination issues, and infection control breaches.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to address a grievance timely for 1 of 3 residents reviewed for property (Resident 63). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate a reportable incident for 1 of 1 residents reviewed for abuse (Resident 103). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and assistance to perform activities of daily living for 4 of 7 residents reviewed (Residents 23, 53, 73, 88, and 94). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders, including failure to notify physician timely and follow orders for ace wraps and lab draws for 4 of 4 residents reviewed (Residents 3, 103, 109, 195). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a sling pad used on a mechanical stand up lift was not defective prior to transferring a resident (Resident 53). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure daily weights were obtained per physician orders for 1 of 3 residents reviewed for nutrition (Resident 88). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate treatment and services were provided to prevent possible complication of feeding tube by not flushing the feeding tube after checking residual (Resident 54). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe, appropriate pain management timely for 1 of 2 residents reviewed for pain (Resident 200). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a pharmacist's irregularity report was acted upon timely for 1 of 5 residents reviewed for unnecessary medications (Resident 48). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to discard expired insulin prior to administration and ensure medications were not preset for 3 residents for 2 of 5 medication carts observed (Residents 88, 53, 42, and 63). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored properly and thermometers were present in a cold bar refrigerator, potentially affecting all residents (135). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and coordinate dental services timely for 4 of 6 residents reviewed for dental services (Residents 53, 74, 94, and 118). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection control guidelines related to glove use, medical equipment cleaning, hand hygiene, and wound care for 3 of 4 residents reviewed (Residents 25, 78, and 93). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missing clothing items: 14
Residents reviewed for ADLs: 7
Residents using stand up lift: 4
Total residents affected by food storage issue: 135
Medication doses administered: 10
Expired insulin open date: Jan 24, 2020
Pain level: 10
Pain level: 2
Feeding tube residual volume: 290
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Family Member 25 | Reported missing clothing for Resident 63. | |
| Social Services 19 | Interviewed regarding grievance for Resident 63. | |
| Environmental Services (ES) | Reported grievance form pinned in laundry room for Resident 63. | |
| LPN 30 | Licensed Practical Nurse | Involved in investigation of Resident 103 fall. |
| DA 31 | Dietary Aide | Involved in investigation of Resident 103 fall. |
| CNA 32 | Certified Nurse Assistant | Not interviewed for Resident 103 fall investigation. |
| Director of Nursing | Provided grievance and abuse policies, interviewed about various findings. | |
| QMA 35 | Qualified Medication Aide | Reported stand up lift shortage. |
| Unit Coordinator 1 | Reported stand up lift shortage. | |
| UC 12 | Unit Coordinator | Assisted with Resident 94's glasses and dental appointment coordination. |
| CNA 8 | Certified Nursing Assistant | Involved in hair drying issue for Resident 73. |
| Family Member 6 | Reported hair drying preference for Resident 73. | |
| Family Member 7 | Reported hair drying preference for Resident 73. | |
| UC 9 | Unit Coordinator | Involved in lab order and pain management discussions. |
| Resident 109 | Reported skin blister not addressed. | |
| Resident 200 | Reported pain not managed timely. | |
| Family Member 10 | Reported Resident 200's pain. | |
| UC 1 | Unit Coordinator | Observed administering insulin without priming and improper glove use. |
| Pharmacist 2 | Reported insulin pen should be primed. | |
| RN 20 | Registered Nurse | Observed with expired insulin on medication cart. |
| RN 22 | Registered Nurse | Observed preset medications in narcotic compartment. |
| Laundry Aide (LA) 15 | Described sling pad washing and inspection process. | |
| RN 3 | Registered Nurse | Observed licking fingers to open medication sleeve. |
| LPN 14 | Licensed Practical Nurse | Observed improper glove use and hand hygiene. |
| CNA 13 | Certified Nursing Assistant | Observed improper glove use during incontinent care. |
| Social Services 25 | Responsible for scheduling dental appointments. | |
| Social Services Assistant (SSA) | Assisted with dental appointment coordination. |
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