Inspection Reports for Westminster Village Kentuckiana
2210 GREENTREE N, IN, 47129
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2025, found Westminster Village Kentuckiana in compliance with no deficiencies cited related to complaint investigations. Earlier inspections showed a mixed record with deficiencies primarily involving medication management, sanitation issues including rodent presence, and documentation related to resident care and safety. Several substantiated complaints involved timely medication availability, meal documentation, and infection control, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaint investigations were unsubstantiated, and corrective actions were documented for substantiated issues. The facility’s inspection history shows improvement, with recent surveys consistently finding compliance after earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
252% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
137 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00460993 and included the Investigation of Residential Complaint IN00460975.
Complaint Details
Complaint IN00460993 - No deficiencies related to the allegations are cited. Complaint IN00460975 - No deficiencies related to the allegation is cited.
Findings
No deficiencies related to the allegations were cited for either complaint. Westminster Village Kentuckiana was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 62
Census Bed Type - Residential: 75
Census Total: 137
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 30
Census Payor Type - Other: 15
Census Payor Type - Total: 62
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
This visit was for the Investigation of Residential Complaint IN00462235.
Complaint Details
Complaint IN00462235 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Westminster Village Kentuckiana was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 79
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
This visit was for the investigation of residential complaints IN00455433 and IN00456660.
Complaint Details
Investigation of complaints IN00455433 and IN00456660 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00455433 and IN00456660 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 70
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 10, 2025
Visit Reason
Paper compliance review related to the Investigation of Nursing Home Complaints IN00450387 and IN00449149 completed on January 22, 2025.
Complaint Details
Investigation of Nursing Home Complaints IN00450387 and IN00449149; both complaints were corrected.
Findings
Westminster Village Kentuckiana was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaints. Both complaints IN00450387 and IN00449149 were corrected.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 10, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey was conducted.
Findings
Westminster Village Kentuckiana 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
Re-Inspection
Census: 56
Capacity: 94
Deficiencies: 0
Date: Feb 6, 2025
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 12/19/2024.
Findings
At this PSR Emergency Preparedness survey, Westminster Village Kentuckiana was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the PSR Life Safety Code survey, the facility 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.
Report Facts
Certified beds: 94
Census: 56
Inspection Report
Complaint Investigation
Census: 59
Capacity: 133
Deficiencies: 6
Date: Jan 21, 2025
Visit Reason
This visit was for the investigation of nursing home complaints IN00449149 and IN00450387, and residential complaints IN00448973 and IN00450286.
Complaint Details
This visit was triggered by complaints IN00449149, IN00450387, IN00448973, and IN00450286. Deficiencies related to allegations were substantiated for complaints IN00449149, IN00450387, and IN00448973. No deficiencies were cited for complaint IN00450286.
Findings
The facility was found deficient in multiple areas including failure to ensure timely availability of discharge medications for a resident, unsanitary kitchen conditions with rodent droppings, rodent infestations in resident rooms and storage areas, and lack of signage for fall hazards due to uneven carpet. Corrective actions and plans of correction were submitted.
Deficiencies (6)
Failed to ensure a resident's medications were available in a timely manner for discharge.
Failed to provide a clean and sanitary kitchen with rodent droppings observed in multiple kitchen and storage areas.
Failed to ensure residents' drawers were free of rodent droppings for 2 of 3 residents reviewed.
Failed to ensure a sanitary and homelike environment for 1 of 3 residents reviewed for sanitation due to rodent presence.
Failed to ensure signage was in place to alert residents of a potential fall hazard due to uneven carpet in the first floor hallway.
Failed to provide a clean and sanitary kitchen and ensure the second floor dining room was free of rodents and rodent droppings.
Report Facts
Residents reviewed for discharge medications: 3
Residents affected by kitchen sanitation: 59
Residents affected by rodent droppings in rooms: 2
Residents affected by rodent presence in apartments: 1
Residents affected by fall hazard due to uneven carpet: 2
Residents affected by rodent droppings in kitchen and dining areas: 74
Pest control visits: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Dearing | Administrator | Signed plan of correction and formal request for desk review. |
| RN 8 | Director of Nursing | Interviewed regarding discharge medication issues and policies. |
| Dietary Manager | Interviewed regarding kitchen sanitation and rodent issues; involved in corrective actions. | |
| Staff Member 7 | Interviewed about rodent problem in resident drawers. | |
| Staff Member 6 | Observed cleaning in Assisted Living kitchen and noted rodent presence. | |
| Executive Director | Interviewed regarding signage for fall hazards and sanitation policies. | |
| Assisted Living Director | Interviewed regarding fall hazard due to uneven carpet. |
Inspection Report
Annual Inspection
Census: 55
Capacity: 94
Deficiencies: 7
Date: Dec 19, 2024
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification survey was conducted by the Indiana Department of Health on 12/19/24 to assess compliance with Medicare and Medicaid participation requirements and state regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but not in compliance with Life Safety Code requirements. Deficiencies included outdated emergency transfer agreements, improper installation of alcohol-based hand rub dispensers, sprinkler system installation and maintenance issues, corridor doors missing or improperly functioning, lack of privacy curtains in some resident rooms, and incomplete documentation of electrical equipment testing.
Deficiencies (7)
Failed to ensure emergency preparedness policies included updated arrangements with other LTC facilities to receive residents in event of limitations or cessation of operations; agreements were outdated dating back to 2008.
Failed to ensure 3 of over 20 alcohol-based hand sanitizer dispensers were not installed over an ignition source as required by NFPA 101.
Failed to maintain ceiling construction around sprinkler heads; one sprinkler head protruded 4-5 inches and one escutcheon was missing.
Failed to provide written documentation of sprinkler system inspection and testing for 1 of 4 quarters in 2024.
Failed to ensure 2 of over 30 corridor doors had no impediment to closing and latching; one door missing and one door latch improperly installed.
Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE) testing as required by NFPA 99.
Failed to provide privacy curtains or tracks in 2 resident sleeping rooms with double occupancy beds.
Report Facts
Certified beds: 94
Census: 55
Alcohol-based hand sanitizer dispensers non-compliant: 3
Sprinkler heads inspected: 6
Corridor doors non-compliant: 2
Resident rooms without privacy curtains: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Dearing | Administrator | Named in relation to findings and plan of correction |
| Maintenance Director | Interviewed regarding multiple deficiencies including emergency preparedness, sprinkler system, hand sanitizer dispensers, corridor doors, and electrical equipment testing |
Inspection Report
Annual Inspection
Census: 133
Deficiencies: 5
Date: Dec 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from December 3 to 10, 2024.
Complaint Details
Investigation of Residential Complaint IN00448413 was included; no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including failure to complete timely discharge Minimum Data Set (MDS) assessments, failure to prevent skin impairment related to improper brief sizing and placement, improper insulin administration technique, failure to maintain dishwasher temperatures within required range, inadequate infection control during meal service, unsanitary conditions in resident snack refrigerators, and failure to maintain clean equipment in resident rooms such as heater vents.
Deficiencies (5)
Failed to complete discharge Minimum Data Set (MDS) assessments for 2 of 19 residents reviewed.
Failed to prevent a skin impairment for 1 of 17 residents reviewed related to improper sizing and placement of briefs.
Failed to ensure proper dose administration related to priming insulin kwikpen needles for 2 residents observed.
Failed to follow dishwasher temperature guidelines for 2 kitchen observations, infection control during dining, and maintain sanitary resident snack refrigerators.
Failed to ensure equipment in resident rooms were kept clean for 6 of 26 rooms reviewed (heater vents covered with black substance).
Report Facts
Census Bed Type - SNF/NF: 55
Census Bed Type - Residential: 78
Total Census: 133
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 9
Number of MDS reviewed: 19
Number of residents reviewed for skin impairment: 17
Number of residents observed for insulin administration: 2
Number of residents affected by dishwasher temperature issue: 55
Number of rooms with unclean heater vents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Dearing | Administrator | Signed plan of correction and referenced in report |
| Nurse 10 | Licensed Practical Nurse | Observed administering insulin without priming the needle |
| CNA 7 | Certified Nurse Aide | Interviewed regarding Resident 3's care and wound |
| CNA 8 | Certified Nurse Aide | Interviewed regarding Resident 3's wound and brief placement |
| CNA 9 | Certified Nurse Aide | Interviewed regarding brief supply and sizing |
| Director of Nursing | Director of Nursing | Provided policies and interviewed regarding wound care and insulin administration |
| Dietary Manager | Dietary Manager | Interviewed regarding dishwasher temperature and meal service hygiene |
| Maintenance Director | Maintenance Director | Interviewed regarding dishwasher repairs and heater vent cleaning |
| Maintenance Technician | Maintenance Technician | Performed cleaning of heater vents |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00442568 completed on October 15, 2024.
Complaint Details
Complaint IN00442568 was investigated and corrected as of October 15, 2024.
Findings
Westminster Village Kentuckiana was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00442568, with survey dates October 11 and 15, 2024.
Complaint Details
Complaint IN00442568 was substantiated with a federal/state deficiency cited at F842 related to meal consumption documentation failures.
Findings
The facility failed to ensure residents' meal consumptions were documented per the plan of care for 2 residents reviewed (Resident B and Resident C). Multiple dates in August, September, and October 2024 showed undocumented meal consumptions. The facility implemented re-education and auditing procedures to improve documentation compliance.
Deficiencies (1)
Failed to ensure residents' meal consumptions were documented per plan of care for Resident B and Resident C.
Report Facts
Census SNF/NF: 52
Census Residential: 83
Total Census: 135
Medicare Census: 7
Medicaid Census: 35
Other Payor Census: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beverly Dell | Director of Nursing | Provided documentation and responsible for coordination and monitoring of corrective actions |
| CNA 5 | Certified Nursing Aide | Interviewed and indicated all resident meals should be documented in the system |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439832 and IN00441017 at Westminster Village Kentuckiana.
Complaint Details
Complaint IN00439832 and Complaint IN00441017 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00439832 and IN00441017 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 55
Census Bed Type - Residential: 84
Census Total: 139
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 32
Census Payor Type - Other: 11
Census Payor Type Total: 55
Inspection Report
Complaint Investigation
Census: 57
Capacity: 146
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00438815 at Westminster Village Kentuckiana.
Complaint Details
Complaint IN00438815 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaint IN00438815 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
SNF/NF Census: 57
Residential Census: 89
Total Capacity: 146
Medicare Census: 10
Medicaid Census: 35
Other Payor Census: 12
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Date: Jun 24, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435759, IN00436006, and IN00436113.
Complaint Details
Complaints IN00435759, IN00436006, and IN00436113 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00435759, IN00436006, and IN00436113 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
SNF/NF Census: 58
Residential Census: 90
Total Census: 148
Medicare Census: 7
Medicaid Census: 34
Other Payor Census: 17
Total Payor Census: 58
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429951.
Complaint Details
Complaint IN00429951 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 relevant regulations.
Report Facts
Census SNF/NF: 56
Census Residential: 81
Total Census: 137
Census Payor Medicare: 7
Census Payor Medicaid: 34
Census Payor Other: 15
Total Census Payor: 56
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00425548 and IN00428146 completed on February 14, 2024.
Complaint Details
The visit was related to complaint investigations IN00425548 and IN00428146, with compliance found.
Findings
Westminster Village Kentuckiana 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 Investigations.
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 3
Date: Feb 12, 2024
Visit Reason
This visit was for the investigation of multiple nursing home and residential complaints, including IN00428146, IN00425548, IN00428377, IN00426475, IN00426486, and IN00427927.
Complaint Details
Complaint IN00425548 was substantiated with deficiency cited at F684. Complaint IN00428146 was substantiated with deficiencies cited at F550 and R0027. Complaints IN00428377, IN00426475, IN00426486, and IN00427927 had no deficiencies related to the allegations.
Findings
The facility was found deficient in ensuring residents were served meals on appropriate dinnerware and in completing quarterly smoking assessments for residents who smoke. Several complaints were substantiated with deficiencies cited at F550, F684, and R0027, while other complaints had no deficiencies related to the allegations.
Deficiencies (3)
Facility failed to ensure residents were served meals on appropriate dinnerware for 2 of 3 residents reviewed for resident rights.
Facility failed to ensure quarterly smoking assessments were completed for 2 of 3 residents reviewed for quality of care.
Facility failed to ensure residents were served meals on appropriate dinnerware for 1 of 3 residents reviewed for resident rights.
Report Facts
Census: 140
Medicare residents: 14
Medicaid residents: 33
Other payor residents: 13
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Dietary Manager | Mentioned regarding use of Styrofoam dinnerware due to contract company leaving and supply issues | |
| Executive Director | ED | Mentioned regarding ordering plates, plate warmers, and meal carts; explained reasons for use of disposable dinnerware |
| Director of Nursing | Mentioned regarding smoking assessment policy and audit | |
| RN 3 | Registered Nurse | Mentioned regarding facility policy on smoking assessments |
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 30, 2023, including a PSR to the State Residential Licensure Survey.
Findings
Westminster Village Kentuckiana 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 SNF/NF: 58
Census Residential: 85
Census Total: 143
Census Payor Medicare: 6
Census Payor Medicaid: 41
Census Payor Other: 11
Census Payor Total: 58
Inspection Report
Life Safety
Census: 60
Capacity: 94
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including fire safety and sprinkling systems. The building is a one-story, fully sprinkled Type V construction with a fire alarm system and smoke detectors in resident areas.
Report Facts
Certified beds: 94
Census: 60
Inspection Report
Annual Inspection
Census: 83
Capacity: 140
Deficiencies: 6
Date: Oct 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from October 23 to October 30, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of changes in condition, inaccurate MDS assessments for antiplatelet therapy, delayed treatment for a resident's yeast infection, unsanitary kitchen conditions, failure to offer pneumococcal vaccinations per CDC guidelines, and inadequate maintenance of essential kitchen equipment.
Deficiencies (6)
Failure to notify the representative of a resident's change in condition for 1 of 22 residents reviewed.
Failed to ensure accurate documentation of the MDS assessment for antiplatelet therapy for 9 of 24 residents reviewed.
Failed to ensure a resident's treatment was timely for 1 of 5 residents reviewed for Quality of Care.
Failed to ensure the kitchen was maintained in a sanitary manner for 3 of 3 observations.
Failed to ensure residents were offered pneumococcal vaccinations as recommended by the CDC for 4 of 5 residents reviewed.
Failed to ensure adequate maintenance of essential kitchen equipment for 3 of 3 observations.
Report Facts
Survey dates: 6
Residents reviewed for notification of changes: 22
Residents reviewed for MDS accuracy: 24
Residents reviewed for Quality of Care: 5
Residents reviewed for pneumococcal immunizations: 5
Residents currently residing: 83
Total licensed capacity: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Wise | Administrator | Signed the report. |
| LPN 7 | Licensed Practical Nurse | Named in notification of change deficiency related to Resident 54. |
| Dietary Cook 4 | Mentioned in kitchen sanitation deficiencies. | |
| Dietary Aide 5 | Mentioned in kitchen sanitation deficiencies. | |
| Maintenance Assistant 6 | Mentioned in maintenance deficiency related to walk-in freezer ice buildup. | |
| Maintenance Director | Interviewed regarding maintenance of freezer equipment. | |
| RN 10 | Registered Nurse | Interviewed regarding Resident 38's medication. |
| RN 13 | Registered Nurse | Interviewed regarding delayed treatment for Resident 31. |
| Unit Manager 8 | Interviewed regarding notification of Resident 54's condition. |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00416971 and IN00414558, as well as the investigation of Residential Complaint IN00413493.
Complaint Details
Complaint IN00416971 - No deficiencies related to the allegations are cited. Complaint IN00414558 - No deficiencies related to the allegations are cited. Complaint IN00413493 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 57
Census Bed Type - Residential: 82
Census Bed Type - Total: 139
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 10
Census Payor Type - Total: 57
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The visit was conducted to investigate Residential Complaint IN00410478 regarding medication delivery procedures at the facility.
Complaint Details
Complaint IN00410478 was substantiated with a state deficiency cited at R0305 related to medication delivery receipt procedures.
Findings
The facility failed to ensure that a licensed nurse received and signed for medications delivered to the facility, as a Qualified Medications Aide (QMA) signed for medications instead, contrary to facility policy.
Deficiencies (1)
Facility failed to ensure a licensed nurse received and signed for medications delivered to the facility for 1 of 19 pharmacy delivery sheets reviewed.
Report Facts
Pharmacy delivery sheets reviewed: 19
Date of medication delivery signed by QMA: Jun 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Wise | Administrator | Provided facility policy document and involved in corrective action plan. |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
This visit was for the investigation of Residential Complaint IN00400077.
Complaint Details
Complaint IN00400077 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00400077 was substantiated; however, no deficiencies related to the allegations were cited. Westminster Village was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Follow-Up
Census: 58
Capacity: 94
Deficiencies: 0
Date: Jan 5, 2023
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 11/07/22.
Findings
At this PSR, Westminster Healthcare Kentuckiana was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Residential Complaint IN00387203 and Nursing Home Complaint IN00390005, conducted in conjunction with the PSR to the Recertification and State Licensure Survey and State Residential Licensure Survey.
Complaint Details
Residential Complaint IN00387203 and Nursing Home Complaint IN00390005 were both corrected.
Findings
Westminster Village Kentuckiana was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Residential Complaint IN00387203. Both the Residential and Nursing Home Complaints were corrected.
Report Facts
Residential Census: 84
Inspection Report
Re-Inspection
Census: 140
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 25, 2022, including PSRs to investigations of residential and nursing home complaints completed earlier in 2022.
Complaint Details
The visit was in conjunction with the PSR to the Investigation of Residential Complaint IN00387203 and Nursing Home Complaint IN00390005, both of which were corrected.
Findings
Westminster Village Kentuckiana was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 during the PSR to the Recertification and State Licensure Survey. Both residential and nursing home complaints were corrected.
Report Facts
Census Bed Type - SNF/NF: 56
Census Bed Type - Residential: 84
Census Bed Type - Total: 140
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 11
Census Payor Type - Total: 56
Inspection Report
Re-Inspection
Census: 140
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Nursing Home Complaint IN00390005 completed on September 30, 2022, in conjunction with PSRs to other complaints and recertification and licensure surveys.
Complaint Details
Investigation of Nursing Home Complaint IN00390005 was completed and found corrected.
Findings
Westminster Village Kentuckiana was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the Nursing Home Complaint IN00390005, which was corrected.
Report Facts
Census Bed Type - SNF/NF: 56
Census Bed Type - Residential: 84
Census Bed Type - Total: 140
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 11
Census Payor Type - Total: 56
Inspection Report
Routine
Census: 60
Capacity: 94
Deficiencies: 22
Date: Nov 7, 2022
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with Emergency Preparedness requirements including policies and procedures, training, testing, emergency power system maintenance, fire safety plan completeness, sprinkler system maintenance, and life safety code requirements such as door hardware and hazardous area protections.
Deficiencies (22)
Emergency preparedness policies and procedures failed to include provision of subsistence needs for staff and residents, including water, pharmaceutical supplies, and sewage and waste disposal.
Emergency preparedness policies and procedures failed to include a system of medical documentation that preserves resident information, protects confidentiality, and maintains availability of records.
Emergency preparedness policies and procedures failed to include use of volunteers in an emergency or other emergency staffing strategies.
Emergency preparedness policies and procedures failed to include the role of the LTC facility under a waiver declared by the Secretary in accordance with section 1135 of the Act.
Emergency preparedness communication plan was not developed and maintained to comply with Federal, State, and local laws.
Emergency preparedness training and testing program was not developed and maintained; no documentation of training/testing was available.
Emergency preparedness training program failed to provide annual training and testing for all staff and volunteers.
Emergency power system inspection, testing, and maintenance requirements were not fully implemented; monthly generator load testing documentation was incomplete and annual load bank and fuel quality tests were not performed.
Delayed egress locking arrangements sign indicated 5 seconds delay instead of required 15 seconds delay.
Hazardous area outside exit discharge was not enclosed by smoke resisting partitions and separated from exit discharge.
Corridor door to Staff Development Room was not provided with a self-closing device.
Cooktop in Physical Therapy room was not shut off at the switch when not in use.
Fire alarm system visual semi-annual inspection did not include all 43 hard wired smoke detectors.
Fire alarm system out of service policy was incomplete and did not include notification procedures and training requirements.
Sprinkler system installation was deficient; outside entrance overhead canopy was not adequately covered by sprinklers.
Sprinkler system maintenance was deficient; sprinkler head in Medical Records Office was covered with dust/dirt and closet storage blocked sprinkler clearance.
Sprinkler system out of service policy was incomplete and did not include notification procedures and training requirements.
Corridor door to Pantry had a clearance of 2.75 inches between bottom of door and floor exceeding the 1 inch maximum allowed.
Oxygen room fire door assembly was not inspected and tested annually as required.
Electrical junction box in interstitial space above drop ceiling had no cover plate and exposed wiring.
Power strips were used as substitutes for fixed wiring in Beauty Shop and resident room 115.
Small oxygen cylinder in 200 Unit Clean Utility room was freestanding and not secured from falling.
Report Facts
Certified beds: 94
Census: 60
Fire drills: 12
Sprinkler heads: 43
Sprinkler heads: 1
Sprinkler heads: 48
Fire drills: 12
Power strips: 2
Oxygen cylinders: 1
Generator load test: 0
Generator fuel test: 0
Delayed egress time: 5
Inspection Report
Recertification
Census: 82
Capacity: 142
Deficiencies: 6
Date: Oct 25, 2022
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 developing and implementing comprehensive person-centered care plans, ensuring appropriate social services follow-up for residents with hallucinations and suicidal ideation, maintaining infection prevention and control practices, and ensuring kitchen and food service areas were clean and in good repair.
Deficiencies (6)
Failed to develop care plans with resident-centered interventions for urinary tract infections and suicidal ideation for 4 of 16 residents reviewed.
Failed to revise and update care plans related to urinary tract infections for 4 of 16 residents reviewed.
Failed to ensure appropriate preventive measures to prevent falls and determine root cause of falls for 5 of 7 residents reviewed.
Failed to provide medically related social services follow-up and monitoring for residents with hallucinations and suicidal ideation for 3 of 4 residents reviewed.
Failed to ensure kitchen, dry storage room and equipment were clean and in good repair during 3 kitchen observations.
Failed to ensure infection control practices were followed related to proper use of personal protective equipment (PPE) for 6 of 9 staff observed.
Report Facts
Facility census: 82
Facility total capacity: 142
Survey dates: 6
Residents reviewed for care plans: 16
Residents reviewed for falls: 7
Kitchen ceiling vents observed: 9
Ceiling sprinkler heads observed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Wise | Administrator | Signed report and interview regarding care plan and social services follow-up |
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 1
Date: Sep 30, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00390005 and IN00390726. Complaint IN00390005 was substantiated with a related deficiency cited, while complaint IN00390726 was substantiated but no deficiencies were cited related to the allegations.
Complaint Details
Complaint IN00390005 was substantiated with a federal/state deficiency cited at F656. Complaint IN00390726 was substantiated but no deficiencies related to the allegations were cited.
Findings
The facility failed to ensure staff followed a resident's plan of care during a transfer and failed to ensure the care plan accurately reflected the type of mechanical lift used for transfers for 1 of 3 residents reviewed (Resident C). The care plan was updated and staff were retrained accordingly.
Deficiencies (1)
Failed to develop and implement a comprehensive person-centered care plan that accurately reflected the type of mechanical lift used by the resident for transfers.
Report Facts
Census total residents: 149
SNF/NF beds: 62
Residential beds: 87
Medicare residents: 9
Medicaid residents: 41
Other payor residents: 12
Residents reviewed for care plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident C's care plan and transfer procedures | |
| RN 3 (Registered Nurse) | Reported CNA 5 transferred Resident C alone using the hoyer lift | |
| CNA 5 (Certified Nursing Assistant) | Transferred Resident C alone using the hoyer lift |
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 1
Date: Sep 1, 2022
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00384372 and Residential Complaint IN00387203, as well as a COVID-19 Infection Control survey.
Complaint Details
Complaint IN00384372 was substantiated with no deficiencies cited. Complaint IN00387203 was substantiated with a state deficiency cited at R0241 related to medication administration errors.
Findings
Complaint IN00384372 was substantiated with no deficiencies cited. Complaint IN00387203 was substantiated with a state deficiency cited related to medication administration errors involving Resident B receiving incorrect medications.
Deficiencies (1)
Facility failed to ensure Resident B received the correct medications, resulting in administration of wrong medications.
Report Facts
Census Bed Type - SNF/NF: 61
Census Bed Type - Residential: 88
Total Census: 149
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 40
Census Payor Type - Other: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in medication administration error involving Resident B |
| Assisted Living Director | Interviewed regarding medication administration education and policies |
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