Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Indiana Veterans Home during CMS and state inspections, most recent first.
Two residents were not treated with dignity and respect when an LPN administered a suppository without informing or obtaining consent from a resident, and a CNA made inappropriate and dismissive remarks to another resident, including refusing to honor care requests and speaking disrespectfully. These actions were inconsistent with facility policies requiring staff to inform residents about care, obtain consent, and maintain respectful communication.
Failure to Follow Metoprolol Hold Parameters: Two residents received metoprolol despite physician orders to hold the medication when HR or BP fell outside specified limits. One resident with CHF, A-fib, and other cardiac conditions had multiple doses given when HR was below 60 or SBP was below 105, and another resident with HTN, dementia, and bipolar disorder received doses when HR was below 55. RN and DON interviews confirmed meds with parameters should be held when vital signs are outside the ordered limits.
A resident with multiple medical conditions sustained a scalp laceration requiring staples after falling during a Hoyer lift transfer. Two CNAs failed to verify that all lift straps were properly secured, resulting in a strap detaching and the resident falling to the floor. The Hoyer lift and sling were found to be in working order, and standard procedures requiring strap checks by two staff were not followed.
A resident with severe cognitive impairment and multiple medical conditions was found with the foot of the bed elevated and a pillow placed under the mattress to prevent getting out of bed, as observed by several CNAs and an LPN. These measures were not ordered for medical treatment and were used to restrict the resident's movement, constituting a physical restraint.
The facility failed to notify physicians when blood sugar readings were outside specified parameters for three residents and administered medications against hold parameters. A resident had a low blood sugar reading without physician notification, while another received medications despite vital signs being below hold parameters. Additionally, elevated blood sugar readings for a third resident were not reported to the physician. Interviews confirmed the lack of documentation and adherence to physician orders.
A resident with a history of falls and Alzheimer's was left unsupervised in a Snoezelen room without a call light, contrary to facility policy. The resident was also found lying on a fall mat for extended periods instead of being in bed with a raised edge mattress as required. Staff interviews confirmed the lack of supervision and adherence to care plans, highlighting significant lapses in safety measures.
A resident with multiple health conditions, including cardiac arrhythmia and dementia, did not receive the correct amount of oxygen as per physician's orders. Observations revealed the resident was either not receiving oxygen or receiving it at a lower rate than prescribed. An LPN confirmed the discrepancy and adjusted the oxygen flow to the correct rate.
A facility failed to follow infection control protocols when an RN entered a resident's EBP room to administer medication via a gastrostomy tube without wearing an isolation gown. The resident, diagnosed with Huntington's disease and dysphagia, was under EBP, requiring staff to wear gloves and gowns during high-contact care. The RN was unaware of the isolation status until reading the sign on the door, and the nursing supervisor confirmed the PPE requirement. Facility policy mandated PPE for residents with feeding tubes.
Failure to Honor Resident Rights to Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two separate incidents involving two residents. In the first incident, a resident with multiple medical diagnoses, including bradycardia, hypotension, congestive heart failure, and obstructive hypertrophic cardiomyopathy, was administered a bisacodyl suppository by an LPN without being informed or asked for consent. The resident, who also had a care plan addressing paranoia and inappropriate sexual behaviors, expressed distress and stated he did not want the suppository, but the LPN proceeded without explanation or acknowledgment of the resident's refusal. Witness statements and interviews confirmed that the LPN did not communicate with the resident before or after the procedure, and the Director of Nursing acknowledged that the nurse failed to inform the resident as required. In the second incident, a CNA made inappropriate and disrespectful remarks to another resident, who had diagnoses including chronic obstructive pulmonary disease, cardiomegaly, dementia, depression, and hemiplegia following a stroke. The CNA told the resident to stop using the call light and made accusatory statements during lunch, blaming the resident for dropping a plate. On another occasion, the CNA refused to lay the resident down after lunch, stating he was not allowed to use the call light repeatedly, and only complied after being instructed to do so. While providing care, the CNA spoke over the resident and made dismissive comments about fulfilling his request. Facility policies reviewed indicated that staff are required to inform residents in advance of care and treatment, ensure informed consent, and maintain dignity and respect in all interactions. Staff interviews confirmed that the actions taken by the LPN and CNA were inconsistent with these policies, as residents were not included in conversations about their care, were not given choices, and were not treated with the respect and dignity required by facility standards.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for metoprolol for two residents whose orders included specific hold parameters based on heart rate and, for one resident, systolic blood pressure. Resident 60 had diagnoses including combined systolic and diastolic heart failure, fistula of the intestine, and cellulitis of the left toe, and a care plan addressing congestive heart failure, mitral valve insufficiency, tricuspid valve insufficiency, and A-fib. The physician ordered metoprolol ER 25 mg daily with instructions to hold for a heart rate less than 60 or a systolic blood pressure less than 105, but the MAR showed the medication was administered multiple times when the resident’s heart rate or systolic blood pressure was below those parameters, including heart rates of 53, 50, 51, 59, 58, 52, 57, 58, 57, and 58, and systolic blood pressures of 104 and 103. Resident 87 had diagnoses including hypertension, cognitive communication deficit, dementia, alcohol dependence with alcohol-induced persisting dementia, and bipolar disorder, and the care plan identified the resident as at risk for fluid volume excess with interventions to provide medication as prescribed and monitor and document blood pressure and heart rate. The physician ordered metoprolol 25 mg, three tablets twice daily, with instructions to hold for a heart rate less than 55, but the MAR showed the morning dose was administered when the heart rate was 54 and again when it was 53. During interviews, RN 2 stated vital signs should be obtained before giving a medication with parameters and that the medication should be held if results were outside the parameters, and the DON stated a medication should not be given if vital signs were outside the physician’s parameters.
Resident Injury During Hoyer Lift Transfer Due to Unsecured Strap
Penalty
Summary
A deficiency occurred when a resident sustained a 3 cm laceration to the posterior scalp during a transfer using a Hoyer lift. The incident took place as two CNAs were transferring the resident from bed to a Broda chair. The resident, who had diagnoses including obsessive compulsive disorder, anemia, restlessness, agitation, and abnormal posture, fell when one of the Hoyer lift straps became unhooked during the transfer. The resident struck the back of his head on the floor and was subsequently sent to the emergency room, where the wound was closed with three staples before returning to the facility. Interviews and facility statements revealed that both CNAs attached the Hoyer lift straps but did not verify together that all straps were secure before initiating the transfer. One CNA reported that the strap on the resident's left side closest to his head was not securely fastened and fell off, resulting in the resident falling from the lift. Subsequent interviews with QMAs and the interim DON confirmed that the Hoyer lift and sling were in proper working order, and that standard procedure required all four straps to be secured and rechecked by two staff members prior to use. The failure to ensure all straps were properly secured directly led to the resident's fall and injury.
Use of Physical Restraint Without Medical Justification for Cognitively Impaired Resident
Penalty
Summary
A resident with diagnoses including Parkinson's disease, dementia, major depressive disorder, and unsteadiness on feet, who was severely cognitively impaired, was found to have the foot of his bed elevated and a pillow placed under his mattress to prevent him from getting out of bed during the night. The resident resided on a locked memory care unit and had been reported as restless, with multiple attempts to get out of bed during the night shift. Multiple staff members, including CNAs and an LPN, observed the elevated bed and pillow under the mattress during their morning rounds and reported these findings during shift change and in interviews. Staff interviews indicated that the interventions were not ordered for medical treatment and were instead used to inhibit the resident's freedom of movement. The staff did not admit to placing the pillow or elevating the bed, but these actions were identified as constituting a physical restraint. Facility policy defined such actions as unreasonable confinement and involuntary seclusion, and the incident was documented as a deficiency related to the use of restraints without appropriate medical justification.
Failure to Notify Physician and Follow Medication Hold Parameters
Penalty
Summary
The facility failed to notify the physician when blood sugar readings were outside the specified parameters for three residents. Resident 93 had a blood sugar reading of 57, which was below the physician's call parameter of 60. Despite the low reading, there was no documentation indicating that the physician was notified. Interviews with the Nursing Supervisor and Dementia Care Director confirmed the absence of notification in the resident's chart. Additionally, the Director of Nursing acknowledged the lack of a policy for following physician's orders. Resident 35 received medications that should have been held according to physician's orders. Digoxin was administered on three occasions when the resident's apical pulse was below the hold parameter of 60. Similarly, Lisinopril was given on multiple occasions when the resident's systolic blood pressure was below the hold parameter of 105. Interviews with the LPN and DON confirmed that medications were administered below the hold parameters, and the facility did not have a policy about following physician's orders. Resident 108 had elevated blood sugar readings that required physician notification, according to the physician's order. On two occasions, the blood sugar readings exceeded the call parameter of 340, but there was no documentation of physician notifications. Interviews with the Dementia Care Director and LPN confirmed the lack of documentation and the expectation to notify the physician for out-of-range blood sugar readings. The facility's policy indicated the need for immediate notification for blood sugars outside the specific call orders, but this was not followed.
Inadequate Supervision and Safety Measures for Resident in Snoezelen Room
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for Resident J, who was left unsupervised in a multi-sensory room for extended periods, contrary to the facility's policy. The resident, who had a history of violent behavior, Alzheimer's disease, and a history of falling, was left in the Snoezelen room without a call light or any means to summon staff. Observations revealed that the room was locked, and the window was covered, making it difficult to monitor the resident. Staff interviews confirmed that the resident was often left alone in the room, and there was no call light available, despite the policy requiring supervision and a maximum stay of 30 minutes. Additionally, the facility failed to provide the appropriate mattress for Resident J, who was at risk for falls. The resident's care plan indicated the need for a raised edge mattress, but observations showed a regular mattress was in use. The resident was frequently found lying on a fall mat on the floor for extended periods, sometimes overnight, instead of being in bed. Documentation and staff interviews indicated that the resident was left on the mat for long hours, which was not in line with the care plan or the facility's fall prevention policy. The facility's policies on supervision in the multi-sensory room and fall prevention were not adhered to, leading to inadequate care for Resident J. The staff did not follow the care plan or the facility's policy, resulting in the resident being left without proper supervision or a means to call for help. The Administrator acknowledged that the staff were not following the current policy for the Snoezelen room or the care plan for the resident, highlighting a significant lapse in the facility's adherence to its own protocols.
Failure to Administer Correct Oxygen Amount to Resident
Penalty
Summary
The facility failed to ensure the correct amount of oxygen was administered to a resident, identified as Resident 64, who was reviewed for respiratory care. During multiple observations, discrepancies were noted in the administration of oxygen. On one occasion, the resident was observed with the portable oxygen tank turned off and no oxygen tubing present, indicating the resident was not receiving any supplemental oxygen. On another occasion, the oxygen was being delivered at 1.5 liters per minute, which was below the physician's order of 2 liters per minute during the day. Resident 64's clinical record indicated several diagnoses, including cardiac arrhythmia, essential primary hypertension, anoxic brain damage, dementia, and other conditions. The resident's care plan highlighted a risk for shortness of breath and respiratory distress, with an approach to administer oxygen as ordered. However, the facility's failure to adhere to the physician's order for oxygen administration was confirmed during an interview with LPN 11, who acknowledged the discrepancy and adjusted the oxygen flow to the correct rate. The facility's policy on oxygen therapy required adherence to physician's orders, which was not followed in this instance.
Failure to Wear PPE in Enhanced Barrier Precaution Room
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols by not wearing personal protective equipment (PPE) in an enhanced barrier precaution (EBP) room for a resident. During an observation, a registered nurse (RN) entered the room of a resident who was in isolation for EBP to administer medication via a gastrostomy tube without wearing an isolation gown. The resident had a gastrostomy tube and was diagnosed with Huntington's disease, dysphagia, and abnormal weight loss. A physician's order indicated the resident was under EBP, requiring staff to wear gloves and gowns during high-contact care activities. The RN was unaware of the isolation status until reading the sign on the resident's door. The nursing supervisor confirmed that staff should wear a gown and gloves when administering medications via a gastrostomy tube to residents in EBP. The facility's policy on EBP, provided by the Assistant Director of Nursing, required PPE for residents with feeding tubes, regardless of MDRO colonization status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Healthcare | 1 mi | ★★★★★ | 7 | 0 |
| Westminster Village - West Lafayette | 2 mi | ★★★★★ | 6 | 1 |
| Cumberland Pointe Health Campus | 2.1 mi | ★★★★★ | 0 | 0 |
| Saint Anthony Rehab And Nursing Center | 3.1 mi | ★★★★★ | 5 | 0 |
| University Place Health Center And Assisted Living | 3.4 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.