Below 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 Westminster Village North during CMS and state inspections, most recent first.
Failure to Provide Written Transfer and Bed Hold Notice: The facility did not ensure written transfer/discharge and bed hold information was given directly to residents or their representatives for multiple hospital transfers. Records showed only packet placement with transporters, phone calls, voicemail messages, or verbal discussions with family/POA for residents with serious medical conditions including respiratory failure, severe cognitive impairment, and fractures, but no documentation of timely written notice as required by policy.
Conflicting code status orders were found in the clinical records of two residents reviewed for advance directives. One resident had active orders for full code and do not resuscitate with limited interventions, and another had active orders for full code and do not resuscitate with comfort measures. An LPN stated that conflicting code status orders needed to be clarified with the physician, and the facility policy required advance directives and code status to be obtained and entered into the record system.
Failure to update PASRR Level I after antipsychotic initiation: two residents had existing PASRR screens that were not revised after new or increased psych symptoms and antipsychotic use. One resident with dementia, hallucinations, and anxiety was started on multiple psychotropics including quetiapine and olanzapine, and another resident with depression and dementia had escalating behaviors, a psych hospital stay, and new Risperdal orders. The SSD confirmed both needed new Level I submissions.
The facility failed to document regularly scheduled care plan meetings with a resident or the resident's representative. The resident had paraplegia, lumbar spina bifida with hydrocephalus, and chronic osteomyelitis with draining sinus, but the clinical record contained no progress notes, documents, or assessments showing a care plan conference had been held. The Social Service Designee stated she could not find any information or notes for the meeting, despite the facility policy requiring discussion of the plan of care at regularly scheduled care plan conferences.
A resident with anxiety, muscle weakness, CHF, and hospice services was repeatedly observed staying in bed in a hospital gown, receiving meals and care in her room, and expressing loneliness, sadness, and a desire to talk with family and be around people more. She said she would get up if staff asked her, but the record showed her activity preferences and willingness to participate were not fully clarified, while staff described her as refusing to get out of bed and the behavior logs showed no refusals of care.
The facility failed to follow physician orders for two residents. One resident with CHF had multiple weight gains above the ordered threshold, but the physician was not notified. Another resident with AFib and CHF received Cardizem even when systolic BP was below the hold parameter. The DON and an LPN confirmed that physician orders and medication parameters were to be followed.
A resident with hemiplegia/hemiparesis after a CVA, repeated falls, and vascular dementia was found on the floor after a CNA transferred the resident without using the required gait belt. The CNA later confirmed the assignment sheet indicated max assist of 1 with a gait belt, and the DON’s assignment document and facility policy also directed gait belt use for transfers.
Inaccurate Documentation of Nutritional Assessments: A resident with a g-tube, severe protein-calorie malnutrition, and an NPO order with ice chips after oral care was observed receiving enteral feed. However, multiple skilled nursing evaluations documented that his nutritional needs were being met through oral nutrition. The ADON and an RN stated the charting was not accurate and should reflect the resident's actual condition.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
A resident with severe cognitive impairment and congestive heart failure did not receive a newly ordered diuretic medication as prescribed due to delays in pharmacy delivery and lack of documented interim measures, resulting in missed doses over a two-day period.
A registered nurse did not perform hand hygiene after removing gloves and failed to wear a gown while providing wound care to a resident under Enhanced Barrier Precautions for MDRO risk. The nurse acknowledged that these steps were normally followed, and the facility's policy required both hand hygiene and appropriate PPE during such high-contact care activities.
A facility failed to ensure the accuracy of an MDS assessment for a resident with dementia and anxiety disorder. The assessment inaccurately reported no behaviors, despite progress notes indicating otherwise. Social Services was responsible for completing the MDS section on behaviors.
A resident with dementia and severe cognitive impairment exhibited frequent aggressive behaviors, but the facility failed to implement a specific care plan with effective interventions. Despite the facility's policy emphasizing person-centered care, staff relied on ineffective redirection techniques and pharmacological interventions without adequately documenting or evaluating non-pharmacological approaches.
A resident with dementia and anxiety disorder received an incorrect dosage of fentanyl patches due to a failure to follow updated physician orders. The resident was prescribed a 25 mcg fentanyl patch every three days, but on one occasion, both a 25 mcg and a 12 mcg patch were administered, resulting in a total dose of 37 mcg. This discrepancy was noted during an interview with the DON, who confirmed that staff should adhere to physician orders.
The facility failed to treat residents with dignity and respect, as evidenced by multiple complaints. A resident reported CNAs turning off call lights without returning, while another faced inappropriate comments from a nurse during personal care. Delays in toileting assistance and lack of tablecloths in the health center contributed to feelings of neglect. A CNA prioritized their break over providing incontinent care, further violating residents' rights.
The facility failed to address a grievance from the resident council regarding the removal of tablecloths in the health center dining rooms. Despite the council's repeated concerns and the facility's policy requiring prompt action and follow-up, no formal grievance documentation or response was provided. The council felt they were treated differently compared to other dining areas in the facility.
The facility failed to address resident grievances effectively, as evidenced by incomplete documentation and lack of follow-up on grievances filed by residents. A resident reported grievances about CNAs being rude, but the forms lacked confirmation and follow-up. Another resident filed grievances about a nurse's refusal to administer insulin correctly and a disagreement over medications, but did not receive follow-up or resolution. Additionally, the facility did not provide a means for residents to file grievances anonymously, as forms were not readily available without asking staff.
The facility failed to ensure proper documentation and follow-up after fall incidents for several residents, leading to deficiencies in care. Residents with dementia, Alzheimer's, and other conditions experienced multiple falls without adequate post-fall assessments or updated care plans. Despite repeated incidents, the facility did not consistently complete incident reports or implement new interventions to prevent further falls.
The facility failed to maintain proper kitchen sanitation and food storage practices. Staff did not wear beard restraints, leading to potential hair contamination. Expired food items were found in the refrigerator, and the dishwasher failed to reach the required temperature, resulting in dirty utensils. Soiled rolling carts were also observed in the food storage area, indicating a lack of adherence to sanitation policies.
The facility failed to maintain an effective pest control program, leading to the presence of flying insects in a food storage area in one of the kitchens. During a tour, tiny flying insects resembling gnats were observed in the air and on products, with a total of nine insects counted. The Kitchen Manager confirmed that there should not be any flying insects in the kitchen or storage area.
A resident, who is 6 foot 8 inches tall and dependent on a wheelchair, was not provided with a suitable wheelchair upon admission to the facility. The available wheelchair was too small, causing discomfort and improper positioning, which affected the resident's ability to sit upright and feed himself. Despite efforts to obtain a specialty wheelchair, delays persisted, leading to the deficiency noted in the report.
A resident with Alzheimer's disease experienced a fall in the facility, but the incident was not initially considered a fall by the nurse, leading to a failure to notify the resident's representative. The facility's policy requires immediate notification of such events, but the clinical record lacked documentation of this notification.
A resident reported a grievance involving a CNA discouraging water intake to avoid frequent changes, which the DON considered abusive. Despite this, the facility did not report the incident to the IDOH as required, and there was no documentation of an investigation. The resident was cognitively intact and had no history of false allegations.
The facility failed to obtain vital signs before administering medication to a resident with specific parameters, did not follow up on a urinalysis for a combative resident, and failed to ensure two residents attended their neurology appointments due to scheduling and transportation errors.
A facility failed to document a physician's order for a resident's continuous oxygen therapy in the EHR and did not change the humidification container as per policy. The resident, on hospice care with multiple diagnoses, had a humidification container with cloudy water that was not bubbling. The hospice provider's order was not entered into the EHR, and the care plan lacked details on continuous oxygen use. The ADON confirmed the facility's responsibility for oxygen-related care, which was not met according to the facility's policy.
A resident with low back pain did not receive a pain-relieving patch as ordered. The care plan required a lidocaine patch to be applied for 12 hours daily. However, the resident reported not receiving the patch at times, and on one occasion, the patch was not replaced as scheduled. An RN confirmed the delay in applying the patch due to time constraints.
A facility failed to conduct pre and post assessments for a resident receiving dialysis, as required by their policy. The resident, with chronic kidney disease and requiring hemodialysis, did not have documented assessments on two scheduled dialysis days. The DON confirmed that staff should have conducted these assessments, which are mandated by the facility's dialysis policy.
A facility failed to ensure medications in its medication carts were not expired, as a vial of Humalog insulin without an expiration date was found. An LPN acknowledged the requirement for dating opened vials and was unable to locate the vial used for a resident with type 2 diabetes. The facility's policy mandates discarding multi-dose vials within 28 days of opening.
Two residents reported receiving unappetizing grilled cheese sandwiches, with one describing it as cold toast with cheese and the other as a microwaved, hard sandwich. The facility's previous method involved using a toaster, but changes were made to use a pan or grill for preparation.
A facility failed to maintain infection control during medication administration. A QMA picked up dropped pills with bare hands, and an RN used a personal blood pressure device on multiple residents without cleaning it between uses. The facility's policy requires avoiding touching medications without gloves.
Failure to Provide Written Transfer and Bed Hold Notice
Penalty
Summary
The facility failed to ensure written discharge and bed hold information was provided directly to residents and/or their representatives at the time of transfer or within 24 hours for emergency hospitalizations. The deficiency involved 4 of 5 residents reviewed for hospitalization: Resident 7, Resident 13, Resident 1, and Resident 4. The facility’s own policy stated that residents or their designated representatives were to be informed in writing at admission, at the time of transfer to a hospital unless it was an emergency, or within 24 hours of an emergency hospitalization, and that written notification at transfer was to include the Notice of Transfer and Discharge and a copy of the bed hold policy. Resident 7 had multiple hospital transfers. On 9/28/25, the resident was sent to the hospital, and the record showed the facility later called the son about the bed hold policy and left a voicemail; the written transfer/discharge form did not show that written bed hold information was given directly to the resident or representative. On 11/18/25, Resident 7 was transferred for shortness of breath after oxygen saturation levels ranged from 70% to 84% on 5 liters of oxygen, with bluish lips and oral cavity and increased drowsiness. The transfer/discharge form again did not indicate that written bed hold or transfer information was given directly to the resident or representative, and subsequent notes showed only phone calls and voicemail messages to family members regarding the bed hold decision. Resident 13, who had severe cognitive impairment and diagnoses including vascular dementia with agitation and psychotic disturbance, was sent to the hospital after a mental status change. The record showed the family was called when the resident left, but the DON stated there was no documentation that the resident’s representative was given a written bed hold policy and transfer paperwork; the paperwork was placed in the packet given to transporters rather than directly to the resident. Resident 1 was transferred to the emergency room for respiratory distress and later admitted to the hospital, and the facility documented phone calls and a verbal discussion with the POA about the bed hold policy, but there was no documentation that written bed hold or transfer/discharge notice was provided prior to or within 24 hours. Resident 4 had two hospitalizations, one after a fall and another after a follow-up appointment that resulted in hospital admission for a procedure; in both instances, the record showed telephone contact with the POA about the bed hold policy, but no documentation that written notice was provided directly to the representative.
Conflicting Code Status Orders in Clinical Records
Penalty
Summary
The facility failed to ensure the clinical record did not contain conflicting physician orders related to code status for 2 of 2 residents reviewed for advance directives. For one resident, the record included an active physician order indicating full code and another active physician order indicating the resident's preference was do not resuscitate with limited interventions. The resident's diagnoses included paraplegia, lumbar spina bifida with hydrocephalus, and chronic osteomyelitis with draining sinus. For a second resident, the clinical record also contained two active physician orders with conflicting code status: one order indicated full code and another indicated do not resuscitate with comfort measure care. The resident's diagnoses included persistent vegetative state, chronic obstructive pulmonary disease, and chronic kidney disease. During interview, an LPN stated that if there was a physician order for both full code and do not resuscitate, it needed to be clarified with the physician. The facility policy stated that the resident's advance directives and/or code status would be obtained and that once a physician order related to code status was received, it would be added to the banner in the record system.
Failure to Update PASRR After Antipsychotic Initiation
Penalty
Summary
The facility failed to ensure a new PASRR Level I was completed after antipsychotic medications were initiated for two residents. One resident had diagnoses including anxiety disorder, dementia with psychotic disturbances, and hallucinations. A PASRR Level I dated 3/27/25 stated the resident did not require a Level II screen and noted there was no evidence of an intellectual/developmental disability or serious behavioral health condition, and that a new screen was required if there was a change in condition or new information. The record later showed psychotropic use for anxiety, restlessness, agitation, hallucinations, and insomnia, including quetiapine started on 4/24/25, mirtazapine started on 4/24/25, Depakote started on 4/10/25, and olanzapine ordered on 5/29/25 for dementia with psychotic disturbances. The second resident had diagnoses including major depression disorder, dementia with mood disturbances, dementia with agitation, and dementia with psychotic disturbances. A PASRR Level I dated 11/21/24 stated no Level II screen was needed at that time and directed that an updated screen be submitted if symptoms increased or other information suggested a serious mental illness. The record showed increased disruptive behaviors, hallucinations, and aggression that led to a psychiatric hospital stay for evaluation and medication adjustment, with new antipsychotic medications ordered after discharge, including Risperdal by mouth and later Risperdal intramuscularly every 14 days. During interview, the SSD stated a new Level I PASRR should be submitted when a resident had new or increased mental health behaviors and when started on a new antipsychotic medication, and confirmed both residents should have had a new Level I submitted.
Missing Documentation of Resident Care Plan Conference
Penalty
Summary
The facility failed to ensure regularly scheduled care plan meetings were held with the resident or the resident's representative and documented in the clinical record for Resident 23. Resident 23's clinical record was reviewed and showed diagnoses including paraplegia, lumbar spina bifida with hydrocephalus, and chronic osteomyelitis with draining sinus. There were no progress notes, documents, or assessments in the record indicating that a care plan meeting had been held with the resident or the resident's representative. During interviews, the Social Service Designee stated she could not find information on a care plan meeting for Resident 23 and later stated she did not have any notes or documentation for a care plan meeting for Resident 23. A facility policy titled Care Planning-Resident Participation stated that the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conference.
Failure to Reevaluate Bedbound Resident’s Preferences and Social Needs
Penalty
Summary
The facility failed to ensure a resident’s preferences were reevaluated so she could maintain the highest practicable level of mental and social needs. Resident 8 was observed in her room on multiple occasions lying in bed in a hospital-style gown, receiving meals in her room and bed baths on shower days, with a high-back wheelchair and Hoyer pad present in the room. She stated she had not been out of bed since admission, relied on staff to get up because she could not do it on her own, and said she would get up if staff asked her. She also said she was unaware the wheelchair was in her room because it was placed out of her sight. Resident 8 repeatedly expressed loneliness and a desire for more social interaction. She stated she wanted to talk to her sister, felt sad and lonely, wanted a change of scenery, and said she used to be very sociable but felt her room was far from everyone else. When asked again whether she would get up if staff came to help her, she said she would very much enjoy getting out of bed. Her room was located at the end of the hall, furthest from the nurse’s station and activity/lounge area, and was the only occupied room in that area. The record showed diagnoses including anxiety disorder, muscle weakness, and chronic congestive heart failure. Admission documentation noted she was initially crying out, resistive to care, and difficult to assess, and the initial activity assessment listed television, movies, and puzzles as interests while her desire for group participation was marked unknown. Care plans identified hospice status, little activity involvement, and a need for 1:1 room visits, with preferred activities listed as CNN, Animal Planet, and Hallmark movies. Staff interviews indicated she was a hospice patient who refused to get out of bed, though the behavior monitoring records showed no refusals of care or offered care, and the DON stated staff should ask her more than once if she wanted to get up because she would refuse the first attempt.
Failure to Follow Physician Orders for Weight Monitoring and Medication Parameters
Penalty
Summary
The facility failed to notify the physician of ordered weight gains for a resident with hypertensive heart disease with heart failure, chronic diastolic congestive heart failure, and paroxysmal atrial fibrillation. The physician had ordered daily weights for congestive heart failure and notification for a weight gain greater than 2 pounds in a day. The resident had documented weight increases of 3.1 pounds, 2.2 pounds, 2.8 pounds, and 5.2 pounds on separate dates, and the physician was not notified for those increases. The DON stated the physician should have been called for the increases in weight, and LPN 5 stated that a weight gain of more than 2 pounds in a day or 5 pounds in a week required physician notification per the order. The facility also failed to hold Cardizem for another resident with atrial fibrillation, chronic combined systolic and diastolic congestive heart failure, and hypertensive heart disease with heart failure when the systolic blood pressure was below the ordered parameter. The physician ordered Cardizem 120 mg daily and to hold it for systolic blood pressure less than 110. The MAR showed the medication was administered when systolic blood pressures were 90, 102, 104, and 108. The DON stated nurses were to follow physician orders and hold medications based on vital signs and parameters, and the facility policy stated medications are to be administered in accordance with prescriber orders.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure a gait belt was used during a transfer for Resident 106. During an observation, the resident was heard screaming in the room and was then found on the floor with CNA 3 standing behind the resident. CNA 3 was wearing a gait belt around her waist, but stated she did not use it to transfer the resident. Resident 106’s clinical record showed diagnoses including hemiplegia and hemiparesis following a cerebral infarction, repeated falls, and vascular dementia. The resident’s care plan did not address using a gait belt for transfers. During interview, CNA 3 stated she did not have her assignment sheet with her at the time and later retrieved it, then indicated the sheet showed Resident 106 required maximum assistance of one staff member and use of a gait belt. QMA 4 stated she used the assignment sheet to determine how to transfer residents and that gait belts were to be used on all residents who were not on mechanical lift transfers. The facility’s assignment document for Resident 106 also indicated one staff member and a gait belt were to be used for transfers, and the facility policy stated gait belts were to be used with residents who could not independently ambulate or transfer for safety.
Inaccurate Documentation of Nutritional Assessments
Penalty
Summary
The facility failed to ensure assessments were accurately documented for one resident reviewed for accurate assessments. Resident 134 was observed with a g-tube running enteral feed and stated he had been readmitted to the facility about 2 weeks earlier after having a feeding tube placed in the hospital. He reported that since the tube was placed, he had not been able to eat or drink anything by mouth except ice chips. The clinical record showed diagnoses including severe protein-calorie malnutrition, gastrostomy tube, and depression, and a hospital discharge document indicated he returned to the facility with a g-tube and was tolerating enteral feeding. The physician's order directed an NPO diet with ice chips after oral care, and the care plan also reflected that he was to remain NPO with ice chips after oral care. However, review of eight skilled nursing evaluation assessments showed nursing staff documented that the resident's nutritional needs were being received and met through oral nutrition. The ADON reviewed the assessments and stated the documentation was not accurate, and RN 7 stated the skilled nursing evaluations should provide an accurate picture of the resident's condition and should be accurate for the resident being assessed.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Administer Newly Ordered Medication
Penalty
Summary
The facility failed to ensure that a newly ordered medication, furosemide 20 mg, was received and administered in a timely manner as ordered by the physician for a resident with congestive heart failure and severe cognitive impairment. The resident was noted to have swelling, redness, and blistering on the left lower extremity, prompting a physician's order for furosemide to be given twice daily for four days. However, the medication was not documented as administered on the evening of the order date, nor the following morning and evening, with the first documented dose given two days after the order was placed. There was no documentation that the facility pharmacy had been contacted regarding the delay in delivery, nor evidence that the medication was accessed from the Emergency Drug Kit, despite its availability. The DON confirmed the pharmacy's delivery schedule and was unable to explain the delay in receiving the medication. The packing slip indicated the medication was delivered two days after the order, and facility records did not show any interim measures taken to provide the medication as ordered.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow proper infection prevention and control protocols during wound care for a resident with a diagnosis that included congestive heart failure and severe cognitive impairment. The resident was under Enhanced Barrier Precautions (EBP) due to being at high risk for acquiring or spreading multidrug-resistant organisms (MDROs), as indicated by the facility's policy. The physician's order required specific wound care procedures for the resident's right foot. During the observed wound care, the RN donned disposable gloves and removed the old dressing, but after removing the gloves in the bathroom, did not perform hand hygiene before applying a new pair of gloves. Additionally, the RN did not don a gown prior to beginning the wound treatment, despite gowns being available in the room and the facility's policy requiring both gloves and gowns for high-contact activities such as wound care under EBP. The RN acknowledged during an interview that she would normally wear a gown and perform hand hygiene after doffing gloves, but failed to do so during this instance. The facility's current EBP policy, provided by the Director of Nursing, clearly outlined the requirements for PPE use and hand hygiene during high-contact care activities for residents at high risk for MDROs.
Inaccurate MDS Assessment for Resident Behaviors
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident's behaviors. Resident B, who has diagnoses including senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder, was reported to have exhibited behaviors on multiple occasions. However, a Significant Change MDS assessment dated 9/30/24 inaccurately indicated that Resident B exhibited no behaviors. This discrepancy was identified through a review of progress notes that documented behaviors on several dates prior to the assessment. An interview with the MDS Coordinator revealed that Social Services was responsible for completing the MDS section regarding behaviors.
Inadequate Behavior Management for Resident with Dementia
Penalty
Summary
The facility failed to adequately care plan for a resident diagnosed with dementia and exhibiting behaviors. Resident B, who had severe cognitive impairment and a history of physical aggression, was not provided with a care plan that included specific interventions for managing her behaviors until several months after admission. Despite frequent occurrences of behaviors such as yelling, refusal of medications, and combative actions, the facility did not document resident-specific approaches or evaluate the effectiveness of interventions. Interviews with facility staff revealed that the behavior management program was insufficient, with no resident-specific interventions being implemented. The staff attempted various redirection techniques, but these were largely ineffective. The facility's policy on behavioral health services emphasized person-centered care and non-pharmacological interventions, but these were not adequately reflected in Resident B's care plan or the staff's approach. The facility's documentation was lacking in terms of recording the approaches taken to manage Resident B's behaviors and the outcomes of these interventions. The Director of Nursing acknowledged that the charting did not reflect the interventions and approaches used. Additionally, the former Social Services Director noted that the facility's behavior management program did not appropriately address the needs of residents with behaviors, relying instead on pharmacological interventions without exploring non-pharmacological options.
Failure to Administer Narcotic Pain Medication per Physician Orders
Penalty
Summary
The facility failed to administer a narcotic pain medication according to physician orders for one resident, identified as Resident B, who was under review for pain management. Resident B's clinical record indicated multiple diagnoses, including senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. A physician order dated October 20, 2024, prescribed a 12 mcg fentanyl patch to be applied every three days, which was later updated on November 6, 2024, by a hospice note to increase the dosage to 25 mcg. A subsequent physician order on November 7, 2024, confirmed the application of a 25 mcg fentanyl patch every three days. However, on November 10, 2024, the controlled drug use record showed that both a 25 mcg and a 12 mcg fentanyl patch were administered, resulting in an incorrect total dose of 37 mcg, contrary to the physician's order of 25 mcg. This error was identified during an interview with the Director of Nursing on December 16, 2024, who confirmed that nursing staff were expected to follow physician orders for medication administration. The facility's policy on medication administration, provided by the DON, emphasized adherence to prescriber orders, including any specified time frames.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple incidents involving residents' complaints about staff behavior and care. Resident N reported that CNAs would turn off her call light, promising to return but failing to do so, leaving her feeling neglected. Resident P recounted an incident where a nurse made an inappropriate comment when asked for assistance with personal care, questioning what Resident P did at home and expressing discomfort with the task. Resident 52 expressed feeling like a second-class citizen due to the lack of tablecloths in the health center compared to other parts of the campus. Resident B experienced long delays in receiving toileting assistance, with staff turning off the call light and not returning as promised, leading to feelings of being treated poorly. Resident K reported waiting a long time for incontinent care, and when she voiced her concerns, a CNA responded by prioritizing their break over the resident's needs. These incidents highlight a pattern of neglect and disrespect towards residents, violating their rights to dignity and self-determination as outlined in the facility's resident rights policy.
Failure to Address Resident Council Grievance on Dining Room Tablecloths
Penalty
Summary
The facility failed to promptly address a grievance raised by the resident council regarding the removal of tablecloths in the health center dining rooms. This issue was first noted in the resident council minutes from April 2024, where a resident expressed dissatisfaction with the absence of tablecloths. Despite the administrator's encouragement to adapt to the changes, the concern persisted, and by July 2024, the resident council reiterated their grievance, noting that tablecloths were still used in the assisted living and independent living dining rooms, but not in the health center. The council felt they were being treated differently and had not received any follow-up on their grievance, other than being informed that the new company had decided to stop using tablecloths. Interviews with facility staff revealed a lack of formal grievance documentation and follow-up. The administrator claimed there were no grievances from the resident council for the months of April, May, or June 2024. The Activity Director, who assisted with the resident council meetings, acknowledged hearing the residents' concerns but admitted she had never filled out grievance forms for general concerns raised by the council. The facility's policy on resident and family grievances, updated in March 2020, mandates that complaints and concerns expressed by the resident council should be promptly addressed by the department manager, with a follow-up response provided to the council. This policy was not adhered to in this instance, leading to the deficiency.
Failure to Address Resident Grievances Timely and Effectively
Penalty
Summary
The facility failed to address resident grievances in a timely and comprehensive manner, as evidenced by the lack of documentation and follow-up on grievances filed by residents. Resident N, who was cognitively intact and had a care plan addressing mood alterations, reported grievances about CNAs being rude and disrespectful. However, the grievance forms lacked confirmation of the grievances, dates of follow-up, and written notifications regarding actions taken. Additionally, there was no documentation of whether the grievances were confirmed or not, and Resident N did not always receive follow-up about her concerns. Resident P, also cognitively intact, filed grievances regarding an evening shift nurse's refusal to administer insulin correctly and a disagreement over blood pressure medications. Despite filing grievances, Resident P did not receive follow-up or resolution, and the grievance forms lacked confirmation of the grievances and dates of follow-up. The forms also did not contain information on whether the grievances were confirmed or not. Resident P expressed a preference for a different nurse but was told no other nurse was available, leading to reluctance in filing further grievances due to fear of retaliation. Resident R's family filed grievances concerning communication issues related to the resident's care and requests for an x-ray due to back pain. The grievance forms did not include confirmation of the grievances or follow-up dates. Additionally, the facility did not provide a means for residents to file grievances anonymously, as grievance forms were not readily available on the units without asking staff. The facility's grievance policy required written decisions and follow-up information, but these were not consistently provided, leading to deficiencies in addressing resident grievances.
Inadequate Fall Management and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure proper documentation and follow-up after fall incidents for several residents, leading to deficiencies in care. Resident E, who had dementia and a history of falls, experienced multiple falls without adequate post-fall assessments or updated care plans. Despite several incidents, including falls due to environmental hazards and poor supervision, the facility did not consistently complete incident reports or implement new interventions to prevent further falls. Resident E's care plan was outdated, and post-fall assessments were not conducted every shift for the required 72 hours. Resident C, diagnosed with congestive heart failure and dementia, also experienced multiple falls without proper documentation or intervention. The facility failed to complete post-fall assessments every shift for three days, and there was a lack of new interventions to prevent future falls. Despite Resident C's cognitive decline and increased dependency, the facility did not adequately address her fall risk, leading to repeated incidents. Other residents, including Residents F, M, and D, also experienced falls without proper follow-up. Resident F, with Alzheimer's disease, had falls that were not properly assessed or documented, and post-fall assessments were incomplete. Resident M, who had a stroke, experienced a fall during a transfer, but the facility did not conduct post-fall assessments as required. Resident D, with left-sided hemiplegia, had multiple falls without incident reports or updated care plans, and necessary equipment like a reacher was missing from his room.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean, sanitized, and well-organized kitchen environment, which led to several deficiencies. Observations revealed that staff did not wear beard restraints, which could lead to hair contamination in food. Additionally, the facility did not properly manage food storage, as expired items such as Jello cups and hot dogs were found in the refrigerator. The facility's policy requires that foods past their expiration date be discarded and that all food be stored to prevent contamination. Further deficiencies were noted in the operation of kitchen equipment and cleanliness. The dishwasher in kitchen 2 failed to reach the minimum required wash temperature of 150 degrees Fahrenheit, resulting in dirty silverware and plates. Despite attempts to repair the dishwasher, it remained out of order. Additionally, soiled rolling carts were observed in the food storage area, indicating a failure to follow the facility's sanitation policy, which requires that kitchenware and food-contact surfaces be cleaned and sanitized after each use.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flying insects in a food storage area within one of the two kitchens. This deficiency potentially affected 97 out of 123 residents. During a tour of kitchen 1, conducted with the Kitchen Manager and Dining Service Director, tiny flying insects resembling gnats were observed in the air and on products in the storage area. A total of nine insects were counted in the immediate area. An interview with the Kitchen Manager confirmed that there should not be any flying insects in the kitchen or storage area.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to provide a wheelchair that accommodated the height of a resident, identified as Resident D, who was 6 foot 8 inches tall and dependent on a wheelchair for mobility. Upon admission, Resident D did not have his own wheelchair, and the facility provided him with the largest available wheelchair, which was still too small. This resulted in discomfort and improper positioning, as observed on multiple occasions where Resident D's hips did not touch the back of the wheelchair seat, and his feet were on the floor with his left ankle turning inward. Resident D expressed that the wheelchair was uncomfortable and caused him pain, impacting his ability to sit upright and feed himself properly. The facility's therapy department had contacted an outside vendor for a specialty wheelchair shortly after Resident D's admission, but there were delays in obtaining a suitable chair. Despite follow-ups and inquiries about a sturdier, long-term solution, the facility had not yet received a quote for a more appropriate wheelchair by the time of the survey. The lack of timely provision of an appropriate wheelchair for Resident D, who had a history of traumatic brain injury and left-sided hemiplegia, contributed to the deficiency noted in the report.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to notify a resident's representative of a fall event involving Resident F, who was cognitively impaired and had a diagnosis including Alzheimer's disease. The resident had a care plan indicating a potential for falls due to deconditioning gait/balance problems and being unaware of safety needs. On a specific date, Resident F was found sitting on the floor in the Aspen activity room, having reportedly gotten up from her wheelchair to sit on the floor. The resident denied falling and reported no pain, and the incident was not initially considered a fall by the nurse who observed the situation. Despite the facility's policy requiring immediate notification of a resident's legal representative or an interested family member in the event of an accident with potential for injury, the clinical record did not include documentation of notification to Resident F's representative regarding the fall. The Director of Nursing confirmed that the nurse did not consider the incident a fall, which led to the lack of notification. This oversight was identified during a complaint investigation, highlighting a deficiency in the facility's adherence to its notification policy.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident, identified as Resident N, to the Indiana Department of Health (IDOH) as required. Resident N, who was cognitively intact and had diagnoses including an unspecified injury of the cervical spinal cord and diabetes, reported a grievance on a specific date. The grievance involved a CNA telling Resident N not to drink as much water to avoid needing frequent changes, which the Director of Nursing (DON) considered abusive. Despite this, there was no documentation or notes from an investigation into the grievance, and the nursing staff denied the allegation. The Social Service Assistant (SSA) who documented the grievance could not recall if Resident N provided names of the staff involved, and Resident N did not have a history of making false allegations. The Administrator confirmed that the grievance was not reported to IDOH, and there was no report or file for the incident. The facility's abuse policy, which mandates immediate or within 24-hour reporting of suspected or known abuse to IDOH, was not followed in this case.
Failure to Administer Medications and Schedule Appointments Appropriately
Penalty
Summary
The facility failed to ensure that vital signs were obtained prior to administering a medication with specific parameters for Resident 32. The resident, diagnosed with chronic kidney disease, congestive heart failure, and diabetes mellitus, was prescribed torsemide, a diuretic medication, with instructions to hold the medication if the systolic blood pressure was less than 100. However, the electronic medication administration record did not indicate that blood pressure was measured before administering the medication from July 2 to July 17, 2024. The facility's policy on measuring blood pressure was not adhered to, as the vital signs were recorded in the evening rather than before medication administration. For Resident 80, the facility did not follow up on a urinalysis ordered by a nurse practitioner due to the resident's dementia, depression, and anxiety disorder. Despite multiple physician orders for a urinalysis with culture and sensitivity, the urine specimen was not collected due to the resident's combative behavior. There were no laboratory results or progress notes indicating follow-up actions regarding the uncollected urinalysis, despite the nurse practitioner's note on November 30, 2023, ordering the test again. The facility also failed to ensure that Residents F and N attended their neurology appointments. Resident F, diagnosed with Alzheimer's disease, was supposed to have a neurology consultation, but due to a scheduling error, the appointment was not confirmed, and transportation was not arranged. Similarly, Resident N missed a neurology appointment due to transportation issues and staff not having the resident ready in time. The facility's transportation services policy was not followed, leading to missed appointments for both residents.
Failure to Document Oxygen Order and Maintain Equipment
Penalty
Summary
The facility failed to ensure that a resident on continuous oxygen therapy had a physician's order for the oxygen documented in the electronic health record (EHR) and did not provide the necessary care and services by neglecting to change the humidification container as per policy. During an observation, it was noted that the humidification container for the resident's oxygen therapy was dated over a month prior, and the water inside was cloudy and not bubbling, indicating improper function. The resident, who was on hospice care, had diagnoses including congestive heart failure, dementia, chronic bronchitis, and anxiety disorder. The facility's staff did not enter the hospice provider's handwritten order for continuous oxygen into the EHR, as confirmed by an LPN. Additionally, the resident's care plan did not include a plan for the use of continuous oxygen, nor was it noted in the Significant Change Minimum Data Set (MDS) assessment. The Assistant Director of Nursing (ADON) confirmed that the care plan should have included the use of continuous oxygen and that the facility's staff, not the hospice company, were responsible for the care services related to oxygen use. The facility's Oxygen Administration policy outlined the need for a physician's order and proper equipment maintenance, which was not adhered to in this case.
Failure to Administer Pain Patch as Ordered
Penalty
Summary
The facility failed to administer a pain-relieving patch as ordered for a resident, identified as Resident K, who was diagnosed with low back pain. The care plan for Resident K indicated that medications should be administered as ordered, including a physician's order for an Aspercreme lidocaine patch to be applied to the lower back for 12 hours daily. The Treatment Administration Record (TAR) documented that the patch was applied and removed as ordered from July 9 through July 17, except for the removal on July 17. During an interview on July 10, Resident K reported not receiving the pain patch as ordered at times, and at the time of the interview, she did not have a patch on her lower back. On July 17, Resident K indicated she had not received a new patch that day, and the patch from July 16 was still in place. Registered Nurse (RN) 6 confirmed that she had not applied the scheduled 8:00 a.m. patch on July 17 due to time constraints and subsequently applied a new patch after the interview.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post assessments for a resident receiving dialysis, as required by their dialysis policy. Resident 176, who was admitted with a diagnosis of chronic kidney disease and required hemodialysis due to renal failure, did not have documented pre or post assessments on two dialysis days. The resident was scheduled to receive dialysis every Monday, Wednesday, and Friday, but the clinical record lacked assessments for the sessions on Friday, 7/12/24, and Monday, 7/15/24. During an interview, the Director of Nursing confirmed that staff should have been conducting these assessments. The facility's dialysis policy mandates providing necessary care and treatment consistent with professional standards, physician orders, and the resident's care plan, which was not adhered to in this case.
Expired Medication Found in Facility's Medication Cart
Penalty
Summary
The facility failed to ensure that medications stored in the medication carts were not expired, as observed during a review of the facility's medication storage rooms and carts. Specifically, a multi-dose vial of Humalog insulin was found in a medication cart without an expiration date, despite being opened on a previous date. The insulin was intended for Resident P, who has a diagnosis of type 2 diabetes mellitus and requires insulin administration based on a sliding scale for blood sugar readings. During an interview, an LPN acknowledged that all opened insulin vials should have an open date and an expiration date, and that they expire 28 days after opening. However, the LPN was unable to provide the vial from which the insulin was administered to Resident P at 7:00 a.m. on the day of the observation, despite searching the medication cart and room. The facility's policy requires that multi-dose vials be dated and discarded within 28 days of opening, and that outdated medications be returned or destroyed as instructed by the dispensing pharmacy.
Deficiency in Providing Palatable Grilled Cheese Sandwiches
Penalty
Summary
The facility failed to provide palatable grilled cheese sandwiches to two residents, both of whom were cognitively intact. Resident 62 reported receiving a sandwich that consisted of two pieces of toast with a cold slice of cheese in the middle, which was not appetizing as the cheese was not melted nor grilled. Similarly, Resident 93 described receiving a sandwich that was microwaved, resulting in a hard texture, akin to a hockey puck. These incidents were reported during interviews conducted with the residents. The issue was discussed in a Dining Committee Meeting, where feedback regarding the always available menu was addressed. The Director of Dietary Service confirmed that the previous procedure for making grilled cheese sandwiches involved using a toaster rather than grilling them. However, with changes implemented by a new dietary company, the procedure was altered to use a pan or grill instead of a toaster. This change was intended to improve the quality of the sandwiches served to residents.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed in two separate instances. In the first instance, a Qualified Medication Aide (QMA) was observed preparing medications for a resident. During the process, the QMA dropped pills onto the medication cart and picked them up with bare hands before placing them into the medication cup. This occurred with multiple medications, including Senna, glycopyrrolate, and pyridostigmine, all of which were administered to the resident without following proper hygiene protocols. In the second instance, a Registered Nurse (RN) used a personal wrist blood pressure device on multiple residents without cleaning or disinfecting it between uses. The RN used the device on four different residents consecutively, admitting to usually cleaning it between every other resident. The RN was unsure of the cleaning instructions for the device, which had been in her possession for many years. The facility's policy on medication administration procedures, which was provided by the Administrator, clearly states that care should be taken to avoid touching tablets or capsules unless wearing gloves, indicating a breach in protocol.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 910 citations issued within 25 miles in the last 12 months — including the 7 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Mccordsville | 1.9 mi | ★★★★★ | 0 | 0 |
| Castleton Health Care Center | 4.4 mi | ★★★★★ | 36 | 0 |
| Waters Of Castleton Skilled Nursing Facility, The | 4.6 mi | ★★★★★ | 24 | 0 |
| Clearvista Lake Health Campus | 4.6 mi | ★★★★★ | 4 | 0 |
| Hamilton Trace Of Fishers | 6.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.