Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Westminster Village Muncie Inc during CMS and state inspections, most recent first.
Cross contamination occurred during lunch meal service when a cook used the same soiled gloves to handle meal tickets, clean dishes, bread bag wrappers, fries, sandwiches, buns, and hot dogs while serving trays. The cook continued touching food and food-contact items without changing gloves after handling unclean items, and the DON confirmed all 56 residents in the skilled healthcare area ate food prepared in the kitchen.
An LPN failed to follow EBP and hand hygiene during suprapubic catheter care for a resident with a catheter site showing purulent, blood-tinged drainage and redness, while also handling supplies, gloves, keys, and medication equipment without proper infection control. The same LPN also administered contaminated medications to two residents after pills were dropped on the floor or touched with bare hands or gloved hands, then returned to the residents instead of being replaced.
The facility did not have a system in place to document, respond to, or resolve concerns raised by the Resident Council, specifically regarding repeated complaints about food temperature. Required action forms were not completed, and staff were unable to provide evidence of follow-up or resolution, leaving residents uncertain if their concerns were addressed.
Two residents who were transferred to the hospital, one for worsening pain and another after a fall, did not receive the required bed hold policy and transfer/discharge notifications. Clinical records lacked documentation that these notifications were provided to the residents or their representatives, and staff interviews confirmed the omission.
Staff failed to consistently document the administration of narcotic pain medications in both the medication administration record (MAR) and the narcotic log for two residents receiving PRN tramadol and oxycodone. Incomplete and inconsistent documentation was observed, with staff interviews confirming lapses due to time constraints and unclear procedures, despite facility policy requiring accurate record-keeping for all controlled substances.
Staff failed to consistently complete and document shift-to-shift narcotic reconciliations on two medication carts, resulting in missing counts, signatures, and Controlled Substances Record sheets for controlled medications. This included instances where a nurse did not perform the required count due to the off-going nurse leaving early, and where controlled medications lacked proper documentation in the narcotic binder. Residents affected had conditions such as Parkinson's disease, anxiety, osteoarthritis, and spinal stenosis, and were prescribed medications like morphine sulfate and tramadol. Facility policy required these reconciliations, but records showed multiple missed opportunities for proper documentation.
An LPN failed to wear a gown, as required by the facility's Enhanced Barrier Precautions policy, while performing catheter care for a resident with multiple chronic conditions. Although gloves were used and hand hygiene was performed, the omission of the gown during this high-contact procedure was contrary to posted signage and facility policy.
Surveyors found that the facility did not have the State Ombudsman contact information posted and accessible for residents and visitors. During a tour with the DON and an administrator, it was confirmed that the information was missing and that there was no facility policy for posting advocacy numbers, potentially affecting all residents.
The facility failed to securely store medications for all residents on the Bristol Unit, as a medication cart was found unlocked and unattended. Additionally, a resident's prescription eye drops were not labeled with an open date, contrary to facility policy. Staff were unsure about the dating requirements for such medications.
A facility failed to follow CDC guidelines for pneumococcal vaccinations, resulting in a resident not being offered the PCV 20 vaccine. The resident, with a history of heart disease and diabetes, had previously received PCV 13 and PPSV 23 vaccines. An RN relied on the CHIRP system for vaccination records and was unaware of the need to offer the PCV 20 vaccine, indicating a lapse in policy implementation.
Cross Contamination During Meal Service
Penalty
Summary
Food was not served in a method to prevent possible cross contamination and/or foodborne illness for 56 of 56 residents who ate meals served in the skilled unit facility kitchen. During lunch meal service, a cook wearing disposable gloves repeatedly handled resident meal tickets, clean dishes, scoops, tongs, sweet potato fries, sandwich wraps, plate rims, the outside of a bread bag, and other food items with the same gloves. The cook also left the steam table area, took a hot dog out of a bag and placed it on an electric griddle, then returned to the food service line and continued touching meal tickets, plates, fries, and wrap sandwiches with the same soiled gloves. The cook then went to the grill, touched the wrapper on a bag of hot dog buns, removed a bun from the bag, and picked up the hot dog off the grill using gloved fingertips. She placed the hot dog in the palm of her soiled gloved hand and carried it to the steam table service area, where she placed it on a plate and continued serving trays while still touching meal tickets and other food items with the same gloves. During interview, the cook stated meal tickets were taken in packets to the units and handled by both staff and residents before returning to the kitchen, and she had not considered that touching unclean items such as meal tickets and bread bag wrappers contaminated her gloves and required a glove change before touching food. The DON stated all 56 residents in the skilled healthcare area ate food prepared in the facility kitchen.
Infection Control Failures During Catheter Care and Medication Administration
Penalty
Summary
The facility failed to follow enhanced barrier precautions and proper hand hygiene during suprapubic catheter care for a resident with obstructive uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, and Alzheimer's disease. The resident had a suprapubic catheter, was severely cognitively impaired, and required substantial assistance with toileting hygiene, toileting transfers, and walking. During observation, the catheter drainage bag and tubing were directly against the floor, and the resident's room had an enhanced barrier precautions sign posted at the doorway. During catheter care, the LPN placed supplies on top of the resident's personal papers, used previously opened wipes from the bathroom counter, and performed care with the same gloves while handling the catheter site, wipes, and dressing materials. The insertion site had purulent drainage and redness around the tubing, and the old dressing was soiled with purulent and blood-tinged drainage. The LPN did not perform hand hygiene during the observation, did not wear a gown, and left and re-entered the room and medication areas without hand hygiene while handling keys, the medication door, the medication cart, keyboard, and mouse. The facility also failed to handle medications using infection prevention and control measures during medication administration for two residents. For one resident, the LPN spilled medications onto the floor, picked up the contaminated pills with a gloved hand, and returned them to the medication cup without replacing them. For another resident, medications were dropped onto a wheelchair seat and the floor, then picked up with a bare hand and placed back into the resident's hand. In both instances, the contaminated medications were administered to the residents, and the DON stated that medications touched with bare hands, dropped on the floor, or contaminated in any way should have been destroyed and not administered.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to establish and maintain a system to respond to and promptly resolve concerns raised by the Resident Council. Review of Resident Council meeting minutes from April and May showed that concerns regarding food temperature were documented, but the required Resident Council Action Forms were either left blank or not completed. These forms are intended to document the concern, the response, and the action plan, but in both instances, there was no record of follow-up or resolution. Interviews with the Life Enrichment Director revealed that while concerns were sometimes verbally communicated to other departments, there was no documentation of these interactions or any evidence that the concerns were addressed or resolved. Further interviews with residents indicated uncertainty about whether their concerns were ever responded to following council meetings. Dietary staff and the Food Services Director were unaware of the food temperature complaints, and no new processes had been implemented to address the issue. The facility's policy requires that concerns and recommendations from the Resident Council be acted upon and communicated back to the council, but this was not done for the concerns raised in April and May. The lack of documentation and follow-up demonstrates a failure to honor residents' rights to organize and participate in resident groups and to have their concerns addressed.
Failure to Provide Bed Hold Policy and Transfer/Discharge Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide required bed hold policy and transfer/discharge notifications to residents or their representatives during hospital transfers for two residents. In the first case, a resident with diagnoses including acute on chronic diastolic heart failure and hypertension, who was cognitively intact, was transferred to the emergency room after complaining of worsening pain. The clinical record did not indicate that a transfer/discharge form or bed hold policy was provided to the resident or their representative at the time of transfer. In the second case, a resident with primary hemiplegia, hemiparesis following a cerebral infarction, hypertension, and oropharyngeal dysphagia, who was severely cognitively impaired, was sent to the emergency room after a fall resulting in a forehead laceration. The clinical record similarly lacked documentation that the required transfer/discharge form and bed hold policy were provided to the resident or their representative. Interviews with nursing staff and the DON confirmed that these notifications and documentation were not completed as required by facility policy.
Failure to Ensure Accurate Documentation and Staff Competency in Narcotic Administration
Penalty
Summary
The facility failed to ensure staff competency in the administration and reconciliation of narcotic pain medications for two residents. During a medication storage observation, discrepancies were found between the narcotic log and the electronic medication administration record (EMAR) for as-needed (PRN) doses of tramadol and oxycodone. For one resident with an internal joint prosthesis infection and above-knee amputation, the narcotic log showed multiple PRN doses administered, but the EMAR lacked documentation for several of these doses. Similarly, for another resident with a right humerus fracture, diabetes, and hypertension, the EMAR did not reflect all doses recorded in the narcotic log, and some doses were not documented in both records as required. Interviews with nursing staff revealed inconsistent practices regarding documentation, with some staff admitting to not always recording narcotic administration in both the MAR and the narcotic log due to time constraints or lack of clarity on how to document late or amended administrations. The facility's policies require that all controlled substances be documented in both the MAR and the narcotic log, and that the records match. However, audits and staff interviews confirmed that this was not consistently followed, leading to incomplete and inaccurate records for narcotic administration.
Failure to Complete Shift-to-Shift Narcotic Reconciliation and Documentation
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliations were consistently completed to account for controlled medications on two of five medication carts reviewed. During medication storage observations, it was found that the Narcotic Count Log for one unit lacked a count and off-going staff signature when a registered nurse took over the cart at the beginning of his shift. The nurse confirmed that the shift-to-shift count was not completed because the off-going nurse left before the count was done, and review of the Narcotic Count Log revealed multiple dates missing required counts and signatures. Additionally, two controlled medications in the narcotic drawer did not have corresponding Controlled Substances Record sheets in the narcotic binder, and the nurse had not identified or reported these discrepancies due to the lack of reconciliation at the shift change. Review of records showed that shift-to-shift reconciliation was missing for 37 out of 50 opportunities on this cart. The residents involved had diagnoses including Parkinson's disease, anxiety, osteoarthritis, and spinal stenosis, and were prescribed controlled medications such as morphine sulfate and tramadol. On another medication cart, the Narcotic Count Log was missing beginning and ending card count numbers for a specific date. Staff interviews confirmed that both the outgoing and incoming nurses were required to count and sign for narcotics at each shift change, but review of records showed that shift-to-shift reconciliation was missing for 4 out of 45 opportunities. The facility's policy required all controlled substances to be counted and documented at each change of hands of the narcotic cart keys, with both staff members participating in the count and recording the results. Despite this policy, the required documentation and reconciliation were not consistently completed, as evidenced by the missing counts and signatures.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy during catheter care for a resident. During an observation, EBP signage was posted outside the resident's room, clearly indicating that staff must wear gloves and a gown for high-contact resident care activities, including device care such as urinary catheter care. However, an LPN performed catheter care for the resident by donning gloves but did not wear a gown prior to entering the room. The LPN completed the catheter care procedure, including cleaning the resident's penis and catheter tubing, and exited the room after removing gloves and performing hand hygiene. Immediately following the observation, the LPN acknowledged that she had not worn a gown during the procedure and stated that both gloves and gowns should be worn for such high-contact care, but she had forgotten to don the gown. The resident involved had multiple diagnoses, including hypertension, type two diabetes mellitus, unspecified dementia, and stage three chronic kidney disease. Physician orders for the resident included EBP for an indwelling catheter and regular catheter care. The facility's current policy, provided by the DON, specified the requirement for gown and glove use during high-contact activities, including catheter care.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to ensure that the name and contact information for the State Long Term Care Ombudsman was posted and readily available for residents and visitors. During a tour of the skilled areas and nursing home units, surveyors observed that the required Ombudsman information was not posted. The Director of Nursing and an administrator confirmed during the tour that the information was not available and acknowledged it should have been accessible to residents. Additionally, the administrator stated in an interview that the facility did not have a policy regarding the posting of resident advocacy numbers, although they followed state guidelines for such postings. This deficiency had the potential to affect all 57 residents in the facility.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for all 17 residents on the Bristol Unit. During an observation, a medication cart was found unattended and unlocked in a common area, which was confirmed by RN 5, who acknowledged that the cart should have been locked. This cart contained medications for the residents on the unit. Additionally, during a medication administration observation for one resident, an open vial of prescription eye drops, Latanoprost 0.005% solution, was found without an open date. QMA 6, who was administering the medication, indicated that the vial should have been dated but was unsure about the specific requirements for dating prescription eye drops. The facility's policy manual specifies that eye medication bottles with accelerated expiration dates must be dated and initialed upon opening, following manufacturer instructions or facility policy.
Failure to Implement Pneumococcal Vaccination Policy
Penalty
Summary
The facility failed to implement its pneumococcal vaccines policy in accordance with the CDC guidelines, resulting in a deficiency related to the vaccination of a resident. Resident 49, who has a medical history of hypertensive heart disease with heart failure, unspecified chronic atrial fibrillation, and type 2 diabetes mellitus, was not offered the PCV 20 vaccine as recommended by the CDC. The resident's vaccination record showed that she had received the PCV 13 vaccine in 2015 and the PPSV 23 vaccine in 2018, but there was no indication of any other pneumococcal vaccinations being offered. During an interview, RN 3 revealed that she relied solely on the Children and Hoosiers Immunization Registry Program (CHIRP) for vaccination records of new residents and was unaware that Resident 49 should have been offered the PCV 20 vaccine. The facility's policy, which was supposed to align with CDC guidelines, was not effectively implemented, leading to the oversight in offering the appropriate pneumococcal vaccination to the resident.
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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 Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morrison Woods Health Campus | 0.6 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Muncie Care Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Bethel Pointe Health And Rehab | 1.5 mi | ★★★★★ | 4 | 0 |
| Woodlands The | 2.6 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Muncie | 3.5 mi | ★★★★★ | 30 | 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.