Inspection Reports for Westminster Village Terre Haute
1120 E. Davis Drive, Terre Haute, IN 47802, IN, 47802
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 21, 2025, found Westminster Village Health & Rehab in compliance with Emergency Preparedness Requirements but cited a deficiency for not conducting quarterly fire drills at unexpected times on two shifts for all four quarters. Earlier inspections showed a pattern of deficiencies related to documentation accuracy, resident care plans, medication management, and safety practices, including issues with transfer notices, behavior management, and infection control. Complaint investigations were mostly unsubstantiated or found no deficiencies, except for one substantiated complaint in March 2025 involving inadequate discharge notice and behavioral health care. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspection results suggest some improvement in emergency preparedness and life safety compliance, although challenges with documentation and resident care remain.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
193% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
77% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 60
Capacity: 78
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The Indiana Department of Health conducted an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey on 05/21/2025 to assess compliance with federal and state regulations including 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
Westminster Village Health & Rehab was found in compliance with Emergency Preparedness Requirements. However, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on two shifts for all four quarters, which could affect all residents, staff, and visitors. A plan of correction was submitted to address this deficiency.
Deficiencies (1)
Failed to conduct quarterly fire drills at unexpected times under varying conditions on two shifts for 4 of 4 quarters.
Report Facts
Certified beds: 78
Census: 60
Fire drills missing unexpected timing: 8
Plan of correction completion date: Jun 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terra Holler | Health Facility Administrator | Named as responsible party and signer of the report |
| Jon McClosky | Maintenance Director | Named as responsible party for conducting and documenting fire drills |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 11
Date: Apr 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Nursing Home Complaint IN00456676 and a State Residential Licensure Survey.
Complaint Details
Complaint IN00456676 was investigated with no deficiencies related to the allegations cited.
Findings
The facility had multiple deficiencies including failure to document full code status accurately, incomplete transfer documentation, untimely transmission of discharge MDS assessments, inaccurate dental status coding in MDS, lack of dementia-specific care plans, delayed treatment of urinary tract infection, improper catheter care, significant unaddressed weight discrepancies, improper storage of respiratory equipment, improper inhaler administration, unlabeled medication vial, and failure to complete preadmission Tuberculin testing.
Deficiencies (11)
Failed to indicate the full code status of a resident accurately upon admission.
Failed to ensure documentation of a resident's transfer included a progress note with pertinent information and notification to the emergency room.
Failed to ensure timely transmission of a discharge Minimum Data Set (MDS) assessment.
Failed to ensure Minimum Data Set (MDS) Assessments were coded accurately regarding residents' dental status.
Failed to ensure a care plan related to dementia care and resident specific interventions were implemented.
Failed to ensure timely treatment for a urinary tract infection and proper catheter care.
Failed to address significant weight discrepancies and notify physician accordingly.
Failed to ensure proper storage and dating of respiratory equipment.
Failed to ensure proper administration of inhaled medication including rinsing and spitting after inhaler use.
Failed to ensure medication vial was labeled properly with open date.
Failed to ensure preadmission Tuberculin test was completed prior to admission.
Report Facts
Survey dates: April 21-28, 2025
Census Bed Type: 99
Medicare residents: 10
Medicaid residents: 28
Other payor residents: 30
Deficiency counts: 8
Weight gain: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terra Holler | Health Facility Administrator | Signed the report |
| LPN 23 | Licensed Practical Nurse | Observed administering inhaled medication improperly and unaware of medication vial open date |
| Director of Nursing | Provided multiple interviews and policies related to deficiencies | |
| Registered Nurse 7 | RN | Interviewed regarding weight monitoring and hospital transfer procedures |
| Registered Nurse 12 | RN | Interviewed regarding weight monitoring procedures |
| Pharmacist 8 | Pharmacist | Interviewed regarding medication order delays |
| Assisted Living Director | Provided interview and plan of correction for inhaler administration |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on April 28, 2025.
Findings
Westminster Village Health and Rehab 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 the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00454240 completed on March 20, 2025.
Complaint Details
Investigation of Complaint IN00454240 completed on March 20, 2025; facility found in compliance.
Findings
Westminster Village Health and Rehab 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: 63
Capacity: 63
Deficiencies: 3
Date: Mar 20, 2025
Visit Reason
This visit was for the investigation of complaints IN00454240, IN00452783, and IN00452733. Complaint IN00454240 had federal/state deficiencies related to the allegations, while the other two complaints had no deficiencies cited.
Complaint Details
Complaint IN00454240 was substantiated with deficiencies cited. Complaints IN00452783 and IN00452733 were not substantiated with deficiencies.
Findings
The facility failed to issue a 30-day notice of transfer or discharge to Resident B when he was not permitted to return after an ER visit. The resident was held in the ER for two days due to refusal of return without a psychiatric evaluation. The facility also failed to allow the resident to return after hospitalization. Behavioral health services and resident-specific interventions were inadequate, with ongoing aggressive behaviors directed at staff. The facility lacked proper documentation and individualized care plans for managing these behaviors.
Deficiencies (3)
Failed to issue a 30-day notice of transfer or discharge to Resident B when he was not permitted to return to the facility after an ER visit.
Failed to allow Resident B to return to the facility after hospitalization despite hospital clearance.
Failed to develop and implement a resident-centered behavior management care plan with individualized interventions for Resident B.
Report Facts
Census: 63
Total Capacity: 63
Medicare Residents: 4
Medicaid Residents: 32
Other Payor Residents: 27
Deficiency Completion Date: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terra Holler | Health Facility Administrator | Named in relation to refusal to allow resident to return and transfer/discharge issues |
Inspection Report
Re-Inspection
Census: 52
Capacity: 78
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with previous deficiencies.
Findings
Westminster Village Health & Rehab was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 48
Capacity: 78
Deficiencies: 4
Date: Apr 25, 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 on 04/25/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included obstructed means of egress due to non-wheeled storage bins, lack of documentation for annual emergency lighting testing, failure to ensure semiannual kitchen exhaust system inspections, and lack of ground fault circuit interrupter (GFCI) protection for an electrical receptacle near a sink.
Deficiencies (4)
Failed to maintain means of egress free from obstructions in 2 of 4 corridors due to 11 small three drawer plastic storage bins with PPE not on wheels.
Failed to document annual testing for all battery backup emergency lights as required.
Failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually as required by NFPA 96.
Failed to ensure 1 of 1 receptacles within 6 feet from a sink had ground fault circuit interrupter (GFCI) protection.
Report Facts
Certified beds: 78
Census: 48
Storage bins: 11
Residents affected: 15
Staff affected: 4
Visitors affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Williams | Administrator | Named as facility administrator and participant in exit conference |
| Lead Maintenance Supervisor | Interviewed regarding deficiencies related to storage bins, emergency lighting testing, kitchen exhaust inspection, and electrical receptacle | |
| Director of Plant Operations | Interviewed regarding deficiencies and corrective actions for life safety code violations |
Inspection Report
Renewal
Census: 82
Capacity: 82
Deficiencies: 11
Date: Mar 27, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from March 20 to 27, 2024.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, bowel/bladder incontinence and catheter use, nutrition/hydration status maintenance, dialysis post-assessment, drug regimen management, medication labeling and storage, food safety and sanitation, infection control program implementation, and assisted living infection control oversight.
Deficiencies (11)
Failed to ensure an MDS assessment was coded accurately for 1 of 17 MDS assessments reviewed (Resident 2).
Failed to obtain a supporting diagnosis for an indwelling Foley catheter for 1 of 3 residents reviewed for catheters (Resident 52).
Failed to address significant weight discrepancy for 1 of 2 residents reviewed for nutrition (Resident 1).
Failed to ensure a post dialysis assessment was completed on 1 of 1 resident reviewed for dialysis (Resident 23).
Failed to ensure verbal physician's orders were counter signed per pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents 37 and 11).
Failed to ensure verbal physician's orders for psychotropic medications were counter signed for 2 of 5 residents reviewed (Residents 47 and 16).
Failed to ensure medications were stored and labeled properly and expired medications were disposed for 2 of 3 medication carts reviewed (Residents 47 and 14).
Failed to prepare and serve food in a sanitary manner including improper beard covering, uncovered food on steam table, debris in food prep areas, and incomplete dishwasher temperature logs.
Failed to maintain proper hand hygiene practices among dietary and nursing staff, including turning off water faucets with bare hands.
Failed to maintain separation between clean and soiled linen in laundry area; clean linens were uncovered and stored in soiled laundry area.
Failed to ensure infection control program was completed for assisted living residents; lack of infection control and antibiotic stewardship tracking for assisted living.
Report Facts
Survey dates: 6
Census SNF beds: 54
Census Residential beds: 28
Total census: 82
Total capacity: 82
Residents reviewed for MDS accuracy: 17
Residents reviewed for catheter use: 3
Residents reviewed for nutrition: 2
Residents reviewed for dialysis: 1
Residents reviewed for unnecessary medications: 5
Residents reviewed for psychotropic medications: 5
Medication carts reviewed: 3
Dietary observations: 3
Residents in assisted living: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Williams | Administrator | Signed report and involved in interviews |
| Employee 5 | Dietary Staff | Observed with beard cover not covering mustache and educated on hygiene |
| Employee 17 | Dietary Staff | Observed with beard cover not covering mustache and educated on hygiene |
| Employee 6 | Dietary Staff | Observed serving food without gloves and improper hand hygiene |
| Employee 3 | Dietary Staff | Observed improper hand hygiene |
| Employee 16 | Dietary Staff | Observed improper hand hygiene |
| CNA 4 | Certified Nursing Assistant | Observed improper hand hygiene during dining service |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding hand hygiene and weight discrepancies |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding insulin storage |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding dialysis assessments |
| LPN 14 | Licensed Practical Nurse | Interviewed regarding hand hygiene |
| Employee 12 | Laundry Staff | Interviewed regarding laundry storage and handling |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including catheter diagnosis, insulin storage, dialysis, and hand hygiene |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding catheter diagnosis and weight discrepancies |
| Dietary Director | Dietary Director | Observed and interviewed regarding food safety and hand hygiene |
| Infection Prevention Nurse 8 | Infection Prevention Nurse | Interviewed regarding infection control program for assisted living |
| Supervising Nurse | Supervising Nurse | Interviewed regarding infection control program for assisted living |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey.
Findings
Westminster Village Health and Rehab 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 Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 82
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00424895, IN00425765, IN00427427, and IN00428411 at Westminster Village Health & Rehab.
Complaint Details
Complaints IN00424895, IN00425765, IN00427427, and IN00428411 were investigated and found to have no deficiencies related to the allegations.
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 and 410 IAC 16.2-3.1 regarding the investigation of the complaints.
Report Facts
Census SNF/NF: 56
Census Residential: 26
Total Census: 82
Census Medicare: 14
Census Medicaid: 24
Census Other: 18
Total Census Payor Type: 56
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00414733.
Complaint Details
Complaint IN00414733 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00414733 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census: 58
Total Capacity: 58
Medicare Census: 10
Medicaid Census: 31
Other Payor Census: 17
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00400795 and IN00404008.
Complaint Details
Investigation of Complaints IN00400795 and IN00404008 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaints IN00400795 and IN00404008 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Report Facts
Census Bed Type - SNF/NF: 47
Census Bed Type - Residential: 25
Total Census: 72
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 15
Total Census Payor: 47
Inspection Report
Re-Inspection
Census: 47
Capacity: 78
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
A Post-Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 01/23/23.
Findings
At this PSR survey, Westminster Village Health & Rehab was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Routine
Census: 54
Capacity: 78
Deficiencies: 5
Date: Jan 23, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare and 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 twice per year. Life Safety Code deficiencies included a self-closing door that failed to latch, missing quarterly fire drills on multiple shifts, use of a prohibited portable space heater, and use of daisy chained power cords.
Deficiencies (5)
Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills.
Activities Closet door failed to self-close and latch as required for hazardous area enclosure.
Failed to conduct quarterly fire drills for 3 of 4 quarters on multiple shifts.
Portable space heater found in Scheduler/Medical Supplies office, prohibited in facility.
Power cords were daisy chained in Scheduler/Medical Supplies office, prohibited as substitute for fixed wiring.
Report Facts
Certified beds: 78
Census: 54
Fire drills missing: 3
Fire drills planned: 3
Self-closing door inspections: 5
Power cord inspections: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Williams | Administrator | Named as Administrator responsible for compliance and education related to deficiencies. |
Inspection Report
Annual Inspection
Census: 24
Capacity: 75
Deficiencies: 14
Date: Jan 18, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including resident self-determination, transfer and discharge documentation, bed hold policy notification, accuracy of Minimum Data Set (MDS) assessments, provision of nail care, pressure ulcer assessment and treatment, nutrition and hydration status maintenance, dialysis care, medication administration documentation, psychotropic medication management, staff certification, and employee tuberculosis screening.
Deficiencies (14)
Failed to ensure residents were provided showers as preferred for 1 of 24 residents reviewed for choices (Resident 100).
Failed to ensure documented evidence of notification to the receiving hospital prior to transfer for 1 of 4 residents reviewed for hospitalization (Resident 9).
Failed to ensure transfer/discharge documents were developed and provided for hospital transfers for 2 of 4 residents reviewed for hospitalization (Residents 48 and 9), and notification of the transfer/discharge was provided to the Ombudsman for 1 of 4 residents reviewed for hospitalization (Resident 9).
Failed to ensure a bed hold policy was provided to a resident with a hospitalization for 1 of 4 residents reviewed for hospitalizations (Resident 9).
Failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 4 of 18 residents' MDS assessments reviewed (Residents 18, 5, 14, and 8).
Failed to ensure nail care was provided to a dependent resident for 1 of 24 residents reviewed for activities of daily living (Resident 2).
Failed to assess and treat a Resident's two pressure ulcers present upon admission into the facility for 1 of 1 resident reviewed for pressure ulcers (Resident 100).
Failed to ensure a Resident, who had experienced significant weight loss, received a physician and registered dietician ordered health shake supplement for 1 of 1 resident reviewed for weight loss (Resident 9).
Failed to ensure physician's orders were followed related to monitoring a resident's daily weight and the assessment of his fistula as ordered for 1 of 1 resident reviewed for dialysis (Resident 29).
Failed to ensure documentation of the administration of medications for 1 of 5 residents reviewed for unnecessary medications (Resident 18).
Failed to ensure documented physician rationale for a declination of a gradual dose reduction of a psychotropic medication and documentation of the administration of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident 18).
Failed to ensure scheduled staff were certified in first aid were present on site at all times for 9 of 21 shifts reviewed for staff with CPR and first aid.
Failed to ensure a newly hired employee received a two-step tuberculin skin test at the time of employment for 1 of 10 employee records reviewed (RN 16).
Failed to ensure a newly hired employee received a two-step tuberculin skin test at the time of employment for 1 of 5 employee records reviewed (QMA 17).
Report Facts
Survey dates: 9
Census: 24
Total capacity: 75
Residents reviewed for choices: 24
Residents reviewed for hospitalization: 4
Residents reviewed for MDS accuracy: 18
Residents reviewed for ADL: 24
Residents reviewed for pressure ulcers: 1
Residents reviewed for weight loss: 1
Residents reviewed for dialysis: 1
Residents reviewed for unnecessary medications: 5
Employee records reviewed: 10
Employee records reviewed: 5
Shifts reviewed for staff certification: 21
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey conducted on January 18, 2023.
Findings
Westminster Village Health and Rehab 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 Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 75
Deficiencies: 0
Date: Nov 28, 2022
Visit Reason
This visit was for the investigation of Complaint IN00394936.
Complaint Details
Complaint IN00394936 - Substantiated. No deficiencies related to the allegations are cited.
Findings
The complaint IN00394936 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 49
Census Residential: 26
Total Capacity: 75
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 25
Census Payor Type Other: 18
Total Census Payor: 49
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385823.
Complaint Details
Complaint IN00385823 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00385823 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/SNF: 52
Census Bed Type - Residential: 27
Census Total: 79
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 20
Census Payor Type - Total: 52
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