Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 University Place Health Center And Assisted Living during CMS and state inspections, most recent first.
A resident with dementia, impaired mobility, and an order for mechanical lift transfers with two staff was transferred to and from dinner using a mechanical lift. Before dinner, two CNAs assisted with the transfer without incident, but after dinner one CNA performed the mechanical lift transfer alone, contrary to the care plan, facility policy, and lift guidelines requiring at least two staff. Later, staff discovered bruising to the resident’s right shin, severe hip pain, and an absent pedal pulse, and the resident was sent to the ER, where imaging revealed minimally displaced fractures of the right tibia and fibula. Nurses indicated the injury could have occurred during the mechanical lift transfer or from contact with the bed frame, and the exact cause of the fracture was not definitively determined.
PASARR screens were not accurate for two residents with mental health conditions and psychotropic medications. One resident’s PASARR did not include clozapine, which was on admission and later ordered daily, and another resident’s PASARR did not reflect a later depression diagnosis or sertraline use. The admission coordinator stated the PASARRs were not updated timely and that the missing information should have been included.
Failure to provide personal hygiene assistance: A resident with Alzheimer’s disease, dementia, and other diagnoses was care planned for ADL and bathing assistance, but repeated observations showed greasy, uncombed hair and the record did not document hair washing during multiple showers or bed baths. The resident’s representative reported the resident often appeared dirty, while the DON and Administrator were unaware of when the resident last had hair care, and staff said behaviors made showers difficult.
A resident with CHF, AFib, and HTN had a physician order for daily weights, but a required weight was missing and a 4.4-pound one-day weight gain was not documented as reported to the physician. The DON said the facility had no CHF protocol, the dietitian reviewed weights daily but did not notify the physician, and an LPN stated weight gains over 3 pounds in one day or 5 pounds in one week required physician notification.
A resident with dementia and dysphagia waited over an hour for meal service in the dining room, despite needing assistance with eating. The facility's practice of serving independent residents first led to the delay, contrary to the policy of promptly assisting residents to enhance their dining experience.
A facility failed to update a resident's PASARR Level I after a new mental health diagnosis and prescription of an antidepressant. The resident's record showed diagnoses including dementia and major depressive disorder, but the PASARR did not reflect these changes. The Social Service Director confirmed the oversight, noting that the admission staff missed updating the PASARR with the new diagnosis and medication.
A facility failed to hold Carvedilol for a resident with hypertension, a-fib, and stroke history, despite physician orders to withhold if SBP was under 120. On two occasions, the medication was administered when the resident's SBP was below the threshold. Interviews confirmed the oversight, and no progress note was documented.
A resident experienced a significant weight gain over a week, but the facility failed to obtain a follow-up weight or notify the physician as required by policy. The resident, with multiple diagnoses including dementia and a wound, was on a prescribed dietary supplement. Despite the facility's policy mandating reweighing and physician notification for significant weight changes, these actions were not documented.
A facility failed to complete necessary assessments and obtain informed consent before using side rails for a resident. Observations showed a 1/4 side rail in use, despite an earlier assessment indicating they were not needed. No documentation of risks and benefits explanation or consent was found. Interviews revealed a lack of a physician's order until after the rails were applied, and the facility's policy requiring assessment and consent was not followed.
A facility failed to conduct timely AIMS assessments for a resident prescribed Seroquel for dementia with aggression. The resident, with multiple diagnoses including Alzheimer's disease, did not receive the required AIMS assessment upon starting the medication or quarterly thereafter, as per facility policy. The first and only assessment was conducted nearly a year later, as confirmed by the DON.
The facility failed to ensure proper medication storage and labeling, as observed in a medication cart review. Deficiencies included expired medications, improperly labeled medications, and loose pills. Staff interviews revealed lapses in medication management, with expired and discontinued medications found in the cart, indicating non-compliance with the facility's medication storage policy.
Improper One-Person Mechanical Lift Transfer Resulting in Leg Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was kept safe during a mechanical lift transfer, resulting in a right leg fracture. The resident had diagnoses including abnormalities of gait and mobility, lack of coordination, and dementia, and had a physician’s order requiring use of a mechanical lift for all transfers. The resident’s care plan documented impaired transfer ability and required a mechanical lift with a minimum of two staff members for all mechanical lift transfers. On one evening, the resident was transferred for dinner using a mechanical lift by two CNAs, and no pain or problems were reported at that time. Later that evening, one CNA transferred the resident alone using the mechanical lift, contrary to the care plan, facility policy, and mechanical lift guidelines, all of which required at least two staff for safe use. An RN later observed the mechanical lift in the resident’s room with that CNA present and indicated the injury could have been caused during a mechanical transfer. Another nurse indicated the accident could have occurred during a mechanical lift transfer or if the resident’s leg hit the metal portion of the bed frame. The following day, while the resident was being changed, staff noted bruising to the right shin, severe pain in the right hip, and an absent pedal pulse in the right foot. The resident was sent to the emergency room, where imaging showed a minimally displaced oblique fracture of the mid tibial diaphysis and a minimally displaced spiral fracture of the proximal fibular diaphysis. The facility’s investigation documented that the CNA admitted to performing the post-dinner mechanical lift transfer alone and reported no issues during the transfer, but the cause of the fracture was not definitively determined.
PASARR screens were not kept accurate for residents with mental health diagnoses and medications
Penalty
Summary
The facility failed to ensure PASARR screenings were accurate and updated when new mental health diagnoses and medications were initiated for 2 of 2 residents reviewed. Resident 3’s clinical record showed diagnoses including Parkinson’s disease, dementia, anxiety, depression, and a psychotic disorder not due to a substance or known physiological condition. A PASARR level I screen outcome dated 2/10/25 did not include clozapine, an atypical antipsychotic, even though a physician’s order dated 10/3/25 indicated the resident was to receive clozapine 37.5 mg once daily. During interview, the admission coordinator stated Resident 3 was on clozapine on admission and that the medication should have been included on the level I PASARR. Resident 19’s record showed diagnoses including dementia, anxiety, depression, and hypothyroidism. A PASARR level I screen outcome dated 11/7/23 listed anxiety and Buspar, but did not include the later diagnosis of depression. The record showed depression with a start date of 8/29/24 and a physician’s order dated 8/30/24 for sertraline 25 mg once daily for depression. During interview, the admission coordinator stated the PASARR was not updated timely when the new mental health medication and diagnosis were added, and that the depression diagnosis should have been included on the most recent PASARR.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure Resident 29 received assistance with personal hygiene and bathing as care planned. Resident 29 had diagnoses including Alzheimer's disease, cognitive communication deficit, hypertension, glaucoma, a pressure ulcer on the right buttock, and dementia. The care plan dated 6/4/23 directed staff to provide assistance with activities of daily living, including personal hygiene and bathing assistance. Facility shower/body check worksheets showed the resident received six showers or bed baths in October 2025 and five in November 2025 through 11/23/25, but there was no documentation that the resident's hair was washed during those bathing episodes. During multiple observations, Resident 29's hair was noted to be uncombed and greasy, including on 11/20/25, 11/21/25, 11/24/25, and 11/25/25, with the hair described as extremely greasy on the last observation. The resident's representative reported concerns that the resident often appeared dirty and had greasy hair, and staff told the family the resident had behaviors and could not be given a shower. The DON stated the resident had pain and behaviors, did not know when the last shower occurred, and said shower caps could be used to wash the resident's hair; the Administrator said she was unaware of the last time the resident's hair had been washed with a shower cap. CNA 9 stated the resident's showers were scheduled for Mondays and Thursdays.
Missed Daily Weight and No Physician Notification for CHF Resident
Penalty
Summary
The facility failed to ensure a daily weight was obtained as ordered by the physician for a resident with chronic congestive heart failure, atrial fibrillation, and hypertension. The physician’s order dated 11/8/25 directed daily weights, but the clinical record showed a daily weight was missing on 11/14/25. The record also showed that on 11/19/25 the resident had a 4.4-pound weight gain in one day, and the care plan revised on 11/18/25 identified altered cardiovascular status with interventions to monitor, document, and report signs and symptoms of CHF and any weight gain unrelated to intake. The progress notes from 11/8/25 through 11/25/26 did not indicate the resident refused the daily weight on 11/14/25, and they did not show the physician was notified of the 4.4-pound one-day weight gain on 11/19/25. During interviews, the DON stated the facility did not have a CHF protocol and that residents with CHF were discussed in IDT meetings to determine actions, including reweighing to confirm accuracy before deciding whether to notify the physician. The dietitian stated she reviewed weights daily but did not notify the physician on 11/19/25, and an LPN stated that weight gains greater than 3 pounds in one day or 5 pounds in one week required physician notification.
Delayed Meal Service for Resident Requiring Assistance
Penalty
Summary
The facility failed to ensure timely assistance with eating for a resident who required help, leading to a delay in meal service. During a dining observation, it was noted that Resident 10, who needed assistance with eating, waited over an hour to receive her food tray. The first tray was delivered at 11:40 a.m., but Resident 10 did not receive her tray until 12:41 p.m., despite being present in the dining room before other residents who were served ahead of her. The delay was attributed to the facility's practice of serving independent residents first, followed by room trays, and then residents who required feeding assistance. Resident 10's clinical record indicated diagnoses of unspecified dementia, dysphagia, depression, and basal cell carcinoma, with a care plan that included increased nutrient needs and dining assistance. The facility's policy on dining and food services emphasized the importance of promptly assisting residents with eating to enhance their quality of life. However, the observation revealed that the policy was not adhered to, as Resident 10 was left waiting while other residents were served and finished their meals. The Executive Director acknowledged that residents should not have to wait an hour for their trays.
Failure to Update PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a revised Preadmission Screen and Resident Review (PASARR) Level I after a new mental health diagnosis was added and an antidepressant medication was prescribed for a resident. The clinical record review revealed that the resident had diagnoses including dementia without behavioral disturbances, cognitive communication deficit, major depressive disorder, and anxiety disorder. However, the PASARR Level I, dated earlier in the year, indicated no mental health diagnosis or medication. A physician's order later prescribed sertraline, an antidepressant, but no updated PASARR Level I was completed following this change. During an interview, the Social Service Director acknowledged that a new Level I PASARR was not completed when the antidepressant medication was ordered. The responsibility for implementing the PASARR fell to the admission staff, who missed updating the Level I PASARR with the new diagnosis and medication. The facility's policy requires that any resident experiencing a significant change in condition, such as a new mental health diagnosis, must be reassessed by the state-specific agency, which was not done in this case.
Failure to Hold Medication as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Carvedilol for a resident diagnosed with essential hypertension, unspecified atrial fibrillation, and transient cerebral ischemic attack. The physician's order, effective from 11/15/24, specified that Carvedilol should be held if the resident's systolic blood pressure (SBP) was below 120. However, on 11/17/24, the medication was administered during both the AM and PM shifts despite the resident's SBP being recorded at 117 and 113, respectively. Interviews with RN 2 and the Director of Nursing confirmed that the medication was not held as required, and no progress note was documented in the resident's chart. The facility's policy mandates that medications be administered as prescribed and in accordance with the prescriber's written orders.
Failure to Follow Weight Management Protocols
Penalty
Summary
The facility failed to ensure proper follow-up and notification procedures were followed for a resident who experienced a significant weight gain. The resident, diagnosed with dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder, was prescribed Ensure three times a day due to increased nutrient needs related to a wound. The care plan required monitoring of the resident's weight monthly and oral intake of food and fluids. However, the resident's weight increased from 124.5 pounds to 134.8 pounds within a week, representing an 8.27% weight gain. Despite this significant change, there was no documentation of a follow-up weight being obtained to verify the gain, nor was there any record of the physician being notified. Interviews with the DON and the Registered Dietician revealed that the facility's policy required a reweigh within 72 hours of a significant weight change and physician notification of such changes. The facility's failure to adhere to these policies resulted in a deficiency in managing the resident's weight change appropriately.
Failure to Obtain Consent and Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that proper assessments were completed and informed consent was obtained before the use of side rails for a resident. During multiple observations, a 1/4 side rail was noted to be in use on the resident's bed. The clinical record review revealed that a side rail assessment completed earlier indicated that side rails were not necessary. However, there was no documentation showing that the risks and benefits of side rails were explained to the resident or that consent was obtained prior to their use. Interviews with the facility's Administrator and Director of Nursing confirmed that there was no physician's order for the side rails until after they were already in use. The physician's order was obtained after the side rails were applied, and the necessary assessment and consent were not completed until several days later. The facility's policy on bed safety and bed rails, which requires resident assessment and informed consent before the use of bed rails, was not followed in this instance.
Failure to Conduct Timely AIMS Assessments for Antipsychotic Medication
Penalty
Summary
The facility failed to adhere to its policy and procedure for conducting an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving antipsychotic medication. Resident 16, who had diagnoses including Alzheimer's disease, unspecified dementia with psychotic disturbance, and other conditions, was prescribed Seroquel, an antipsychotic medication, for dementia with aggression. The facility's policy required an AIMS assessment to be completed upon initiating a new antipsychotic medication order and quarterly thereafter to monitor for tardive dyskinesia and other extrapyramidal symptoms. However, the AIMS assessment for Resident 16 was not conducted until nearly a year after the antipsychotic medication was prescribed, with the first and only assessment completed on October 16, 2024. This delay was confirmed during an interview with the Director of Nursing, who acknowledged that the assessment was not performed in accordance with the facility's policy. The lack of timely AIMS assessments represents a failure to monitor the resident for potential adverse reactions to the antipsychotic medication as required by the facility's procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a medication storage review. In one of the medication carts, several deficiencies were noted, including an opened Erythromycin Ophthalmic Ointment that was not dated, and expired SwabCaps. Additionally, expired medications such as Famotidine, Acetaminophen, Loperamide, Docusate Sodium, and Guaifenesin were found in the cart. Blood glucose test strips were also found with an open date that exceeded their expiration date. Interviews with staff revealed that the expired SwabCaps and discontinued Famotidine should not have been in the cart, indicating a lapse in the facility's medication management procedures. Further inspection of the medication cart revealed loose pills and medications without proper labeling, such as Colace tablets with no open date. Staff interviews indicated that nurses were responsible for checking expiration dates and labeling medications upon opening, while the pharmacy conducted audits. However, the presence of expired and improperly labeled medications suggests a failure in adhering to the facility's policy on medication storage, which mandates the removal and destruction of expired medications and proper labeling of opened medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 99 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Cumberland Pointe Health Campus | 1.3 mi | ★★★★★ | 0 | 0 |
| Westminster Village - West Lafayette | 1.4 mi | ★★★★★ | 6 | 1 |
| Heritage Healthcare | 2.4 mi | ★★★★★ | 7 | 0 |
| Saint Anthony Rehab And Nursing Center | 3.1 mi | ★★★★★ | 5 | 0 |
| Indiana Veterans Home | 3.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for University Place Health Center And Assisted Living.
100% money-back within 48 hours.
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.