Inspection Report Summary
The most recent inspection on May 12, 2025, found Westminster Village - West Lafayette in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies related primarily to medication management, resident care documentation, and Life Safety Code issues such as fire barrier maintenance and use of unapproved electrical devices. A substantiated complaint in April 2023 involved a staff member sharing a photo of a resident without consent, which was cited as abuse, but no fines or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated or found no related deficiencies. The facility’s inspection history shows improvement in Life Safety compliance and complaint outcomes in recent visits following earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
82% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 59
Capacity: 72
Deficiencies: 0
Date: May 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/20/2025 by the Indiana Department of Health.
Findings
At this PSR survey, Westminster Village - West Lafayette was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
Paper compliance review related to the Recertification and State Licensure survey and the Investigation of Complaint IN00441342 completed on February 25, 2025.
Complaint Details
Investigation of Complaint IN00441342 was completed and found in compliance.
Findings
Westminster Village-West Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and the Investigation of Complaint IN00441342.
Inspection Report
Life Safety
Census: 66
Capacity: 72
Deficiencies: 2
Date: Mar 20, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies including an unapproved penetration in a fire barrier wall and the use of an unapproved power strip as a substitute for fixed wiring. Corrective actions and education were planned and implemented.
Deficiencies (2)
Failed to ensure the penetration in 1 of 2 fire barrier walls was maintained to ensure fire resistance; unapproved expandable spray foam was used instead of approved fire stop material.
Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring; an unapproved power strip was found plugged into a refrigerator six feet from a resident bed.
Report Facts
Facility capacity: 72
Census: 66
Residents potentially affected by fire barrier penetration: 20
Residents potentially affected by power strip use: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristen Patz | Administrator | Signed the report |
| Plant Operations Director | Interviewed and involved in findings related to fire barrier penetration and power strip use | |
| Assistant Plant Operations Director | Present during observations and exit conference | |
| Maintenance Director | Present during observations and exit conference |
Inspection Report
Annual Inspection
Census: 62
Capacity: 126
Deficiencies: 6
Date: Feb 25, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of four complaints.
Complaint Details
Complaint IN00444575 - No deficiencies related to the allegations are cited. Complaint IN00443524 - No deficiencies related to the allegations are cited. Complaint IN00441342 - Federal/state deficiencies related to the allegations are cited at F744. Complaint IN00440547 - No deficiencies related to the allegations are cited.
Findings
The facility was found to have deficiencies related to medication administration parameters, therapy evaluations, dementia care interventions, drug regimen reviews, resident record documentation, and immunizations. Some complaints were substantiated with cited deficiencies, while others were not.
Deficiencies (6)
Failed to ensure staff followed physician's ordered medication parameters for 2 of 5 residents.
Failed to ensure physician's orders were followed and therapy evaluations were completed timely for 2 of 4 residents.
Failed to ensure staff initiated new person-centered dementia care interventions and wanderguard checks for 2 of 5 residents.
Failed to ensure pharmacy provided gradual dose reduction requests for psychotropic medications for 2 of 5 residents.
Failed to ensure behavior and side effect monitoring for psychotropic medications, wound care treatments, and catheter care were documented for 4 of 4 residents.
Failed to ensure influenza and pneumococcal vaccinations were provided for 1 of 5 residents reviewed for immunizations.
Report Facts
Survey dates: February 19, 20, 21, 24 and 25, 2025
Facility number: 93
Residential Census: 62
Total beds: 126
Residents reviewed for medication parameters: 5
Residents reviewed for therapy evaluations: 4
Residents reviewed for dementia care: 5
Residents reviewed for drug regimen: 5
Residents reviewed for documentation: 4
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristen Patz | Administrator | Signed report and plan of correction |
| LPN 4 | Interviewed regarding medication administration and wanderguard procedures | |
| Director of Nursing (DON) | Interviewed regarding medication administration, therapy delays, wanderguard, and documentation | |
| Clinical Executive Director | Provided facility policies and interviewed regarding wanderguard and documentation | |
| Infection Preventionist (IP) 3 | Interviewed regarding immunizations | |
| Registered Nurse (RN) 1 | Interviewed regarding behavior monitoring and medication side effects documentation | |
| Certified Nursing Assistant (CNA) 5 | Interviewed regarding wanderguard presence |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 116
Deficiencies: 0
Date: May 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433420.
Complaint Details
Complaint IN00433420 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00433420 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 62
Total Capacity: 116
Inspection Report
Re-Inspection
Census: 67
Capacity: 72
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/20/24 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Westminster Village - West Lafayette 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, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is a one-story sprinklered building with a fire alarm system and smoke detection throughout.
Inspection Report
Life Safety
Census: 58
Capacity: 72
Deficiencies: 2
Date: Feb 20, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified two deficiencies: failure to maintain means of egress free from obstructions in one corridor, and failure to ensure 7 of 12 fire drills included verification of fire alarm signal transmission to the monitoring station.
Deficiencies (2)
Failed to maintain the means of egress free from obstructions in 1 of 8 corridors; a plastic 3 drawer chest without wheels was blocking the corridor.
Failed to ensure 7 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station.
Report Facts
Facility capacity: 72
Census: 58
Fire drills lacking verification: 7
Fire drills reviewed: 12
Corridors inspected: 8
Residents potentially affected: 14
Staff potentially affected: 4
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Montgomery | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
| Plant Operations Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Renewal
Census: 69
Capacity: 130
Deficiencies: 5
Date: Jan 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from January 22 to 26, 2024.
Findings
The facility was found to have deficiencies related to ADL care for dependent residents, quality of care including failure to follow physician orders for weights and accu-checks, posted nurse staffing information inaccuracies, resident call system malfunctions, and environmental issues such as items stored on floors and damaged walls and carpet. Plans of correction and audits were implemented to address these issues.
Deficiencies (5)
Failed to ensure a resident received mouth care twice daily as ordered.
Failed to ensure residents with congestive heart failure were weighed as ordered, accu-checks completed as ordered, and non-pressure skin impairments assessed and documented for 4 residents.
Failed to ensure posted nurse staffing was up to date and had correct hours of staff nurses for 2 posted nurse staffing lists.
Failed to ensure all areas of the wireless call system were functioning properly for 2 residents.
Failed to ensure items were not stored on the floor in resident rooms, carpet squares edges were not peeling, and walls were free of gouges for 4 rooms.
Report Facts
Survey dates: 5
Census Bed Type: 130
Residential Census: 69
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Montgomery | Administrator | Signed the report and plan of correction |
| UM 7 | Unit Manager | Interviewed regarding weights, call light system, and nurse staffing |
| DON | Director of Nursing | Interviewed regarding weights, accu-checks, call light system, and policies |
| RN 2 | Interviewed regarding resident call light not being answered | |
| CNA 6 | Certified Nurse Aide | Interviewed regarding items on floor and call light system |
| QMA 3 | Qualified Medication Aide | Interviewed regarding resident call light |
| QMA 5 | Qualified Medication Aide | Interviewed regarding pager battery |
| LPN 9 | Licensed Practical Nurse | Interviewed regarding bandage on resident's toe |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding bandage on resident's toe |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 26, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey.
Findings
Westminster Village - West Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416506.
Complaint Details
Complaint IN00416506 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 110
Census Bed Type - SNF: 14
Census Bed Type - SNF/NF: 47
Census Bed Type - Residential: 49
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 1
Census Payor Type - Other: 46
Census Payor Type - Total: 61
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00407001 completed on April 27, 2023.
Complaint Details
Investigation of Complaint IN00407001 completed on April 27, 2023; facility found in compliance.
Findings
Westminster Village-West Lafayette was found to be in compliance with 42 CFR Part 43, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407001 regarding allegations of abuse involving a resident at Westminster Village - West Lafayette.
Complaint Details
Complaint IN00407001 was substantiated with federal and state deficiencies cited related to abuse allegations involving Resident B. The photo of the resident on the floor was shared by staff via Snapchat, violating abuse and cell phone usage policies.
Findings
The facility failed to ensure a resident was free from abuse when a staff member took and shared a photo of a resident lying on the floor without consent, violating the facility's abuse and cell phone policies. The investigation confirmed the photo was taken and shared via social media, constituting abuse through technology.
Deficiencies (1)
Failure to ensure a resident was free from abuse when staff took and shared a photo of the resident lying on the floor.
Report Facts
Census bed type total: 106
SNF beds: 8
SNF/NF beds: 61
Residential beds: 37
Medicare census: 8
Medicaid census: 1
Other payor census: 60
Skin tear size: 2.5
Skin tear width: 1.7
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Blankenship | Health Facility Administrator | Signed the report |
| CNA 6 | Staff member who found Resident B on the floor and took the photo | |
| CNA 7 | Staff member who received the photo and shared it, currently on medical leave | |
| RN 3 | Interviewed regarding Resident B's refusal to get out of bed | |
| Former Staff Member 13 | Reported the photo to the Indiana Department of Health | |
| Director of Nursing | Director of Nursing | Interviewed about the photo and facility policies |
Inspection Report
Life Safety
Census: 68
Capacity: 72
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. All resident-accessible areas and service areas were sprinklered.
Inspection Report
Re-Inspection
Census: 64
Capacity: 99
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on November 3, 2022, including a PSR to the State Residential Licensure survey.
Findings
Westminster Village - West Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census by bed type: 5
Census by bed type: 59
Census by bed type: 35
Total census: 64
Inspection Report
Life Safety
Census: 68
Capacity: 72
Deficiencies: 2
Date: Nov 28, 2022
Visit Reason
A 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
The facility was found not in compliance with Requirements for Participation in Medicare/Medicaid related to Life Safety Code. Deficiencies included failure to maintain fire alarm system inspections and failure to perform annual fuel quality tests on diesel generators.
Deficiencies (2)
Failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72; no documentation of semi-annual visual inspection.
Failed to ensure an annual fuel quality test was performed for three of the facility's four diesel powered generators.
Report Facts
Facility capacity: 72
Census: 68
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Steele | Administrator | Named in relation to exit conference and review of findings |
| Plant Operations Director | Interviewed regarding fire alarm system inspection and generator fuel testing; name not provided |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 7
Date: Nov 3, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from October 27 to November 3, 2022.
Findings
The facility was found deficient in multiple areas including failure to complete PASARR assessments for residents with new mental health diagnoses and antipsychotic prescriptions, failure to provide scheduled showers to residents needing assistance, incomplete physician orders for oxygen use, lack of monitoring for residents on long-term prophylactic antibiotics, inappropriate use and monitoring of psychotropic medications, failure to follow puree food recipes, and failure to prevent and investigate an elopement incident involving a cognitively impaired resident.
Deficiencies (7)
Failed to ensure PASARR was completed when new mental health diagnosis and antipsychotic medication prescribed for 2 of 3 residents.
Failed to ensure residents needing assistance with ADLs were provided scheduled showers for 2 of 2 residents reviewed.
Failed to obtain complete physician's orders for oxygen use for 2 of 5 residents reviewed.
Failed to monitor residents on long-term prophylactic antibiotics for side effects for 2 of 2 residents reviewed.
Failed to ensure psychotropic medications were prescribed for approved diagnoses and gradual dose reductions had appropriate clinical rationale for 6 of 8 residents reviewed.
Failed to ensure recipes were followed when preparing puree foods for altered diets for 1 staff member observed.
Failed to ensure a cognitively impaired resident was free from neglect and failed to thoroughly investigate an elopement for 1 resident.
Report Facts
Census Bed Type: 105
PASARR non-compliance: 2
Residents missing scheduled showers: 2
Residents with incomplete oxygen orders: 2
Residents on long-term prophylactic antibiotics lacking monitoring: 2
Residents with psychotropic medication issues: 6
Residents with cognitive impairment at risk for elopement: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Steele | Administrator | Signed report and referenced in plan of correction |
| LPN 3 | Reported resident missing for salon appointment and elopement incident | |
| Social Services Designee | Interviewed regarding PASARR assessments and resident behaviors | |
| CNA 5 | Interviewed regarding shower schedules and resident refusals | |
| Licensed Practical Nurse 2 | Interviewed regarding oxygen order and titration | |
| Assistant Director of Culinary | Interviewed regarding puree food preparation procedures | |
| Facility Pharmacist | Interviewed regarding psychotropic medication use and gradual dose reductions | |
| Salon Staff 4 | Interviewed regarding resident haircut and elopement incident |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00377261.
Complaint Details
Complaint IN00377261 was substantiated with no deficiencies cited related to the allegations.
Findings
The complaint IN00377261 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 64
Medicare residents: 10
Medicaid residents: 1
Other residents: 53
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