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
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
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
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
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.
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