Average — CMS composite of the measures below.
The next survey window likely opens around December 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 - West Lafayette during CMS and state inspections, most recent first.
Failure to Notify MD/On-Call for Change in Condition: A resident with constipation, diarrhea, abdominal distention, and worsening pain developed hypoactive/absent bowel sounds, excessive belching, nausea, and SOB, but staff faxed the MD office instead of directly contacting the MD or on-call provider when the condition worsened. The resident was later sent to the hospital with a perforated bowel, SBO, and necrosis, underwent surgery, and died.
Failure to provide written bed hold policy notice on transfer: Three residents were hospitalized or transferred to the ER for conditions including CHF exacerbation, perforated bowel, rectal bleeding, ileus pattern, and GI bleed, but the EMR had no documentation that the resident or representative received the facility's bed hold policy in writing, including reserve bed payment. The ED confirmed the policy and cost were not given in writing, and the UM stated the bed hold form was to be completed with all transfers.
PASARR Level I was not completed when a resident had a new mental health dx and was started on Rexulti, an atypical antipsychotic, for anxiety. The resident also had buspirone ordered and a care plan for anxious mood with fidgety, restless, tearful, anxious, and agitated behaviors. The SSD stated a new Level I was needed when a new psychotropic med or mental health dx was added, but the screen was not completed until later.
A resident with CHF, dementia, DM, AFib, and anxiety had a physician order for daily post-void weights with notification parameters for significant weight gain, but the MAR showed multiple missed weight entries across several months. The record also showed weight gains of 2.8, 2.5, and 3.5 pounds on separate dates, and no CHF care plan was located in the EMR. Staff interviews indicated CNAs obtained the weights and the nurse documented them in the EHR.
The facility failed to document behavior and side effect monitoring for psychotropic medications, wound care, and catheter care for four residents. A resident with dementia had missing documentation for medication side effects, while another with Parkinson's disease also lacked documentation for medication monitoring. A third resident at risk for pressure ulcers had missing wound care documentation, and a fourth with an indwelling catheter had incomplete catheter care records. Interviews with nursing staff confirmed the documentation should have been completed as per facility policies.
The facility failed to follow physician-ordered medication parameters for two residents. One resident received metoprolol despite having a heart rate and blood pressure below the prescribed limits, while another resident was given midodrine when their systolic blood pressure was above the specified threshold. The DON and an LPN acknowledged these errors, which were contrary to the facility's medication administration policies.
The facility failed to conduct timely therapy evaluations and follow physician orders for two residents, leading to deficiencies in care. One resident, at risk for falls and decreased ADLs, experienced a 17-day delay in therapy evaluation, resulting in a fall. Another resident with contractures faced a 16-day delay in therapy evaluation, despite a physician's order. Facility policies on therapy management and documentation were not followed, contributing to these deficiencies.
The facility failed to implement person-centered dementia care interventions for two residents with wandering behaviors. One resident frequently attempted to exit the facility and triggered alarms, while another had missing documentation for wanderguard checks. The facility did not consistently follow its policies on elopement prevention and documentation, leading to inadequate care for these residents.
The facility failed to conduct required gradual dose reductions (GDR) for psychotropic medications for two residents. One resident, with multiple psychiatric diagnoses, lacked GDR considerations for buspirone, duloxetine, and Zyprexa. Another resident, with Parkinson's and anxiety, did not have a GDR for buspirone. The facility's policy mandates GDR attempts in two separate quarters within the first year and annually thereafter, which was not adhered to.
A facility failed to administer influenza and pneumococcal vaccinations to a resident, despite having informed consents signed. The resident, with multiple diagnoses, had not received a pneumococcal vaccine and had an outdated influenza vaccine. The Infection Preventionist was unaware of the reasons for the oversight, despite facility policies requiring timely vaccination.
Failure to Notify Physician Promptly for Change in Condition
Penalty
Summary
The facility failed to ensure the physician was notified immediately and that on-call services were used when a resident had a change in condition. Resident 67 had multiple diagnoses including morbid obesity, constipation, atrial fibrillation, hypertension with heart failure, repeated falls, and chronic anticoagulation. He was admitted from the hospital with loose stools and a CT showing a prominent colonic stool burden. On admission, his abdomen was round, soft, and distended with bowel sounds present in all four quadrants, and he initially denied shortness of breath and pain. Over the course of the stay, nursing documentation showed ongoing diarrhea, abdominal distention, and later worsening abdominal findings. A nursing note documented the resident complaining of upset stomach, and a standing order for calcium carbonate was faxed to the physician’s office. Later that evening, the resident complained of abdominal pain, said he was constipated, reported not having a regular bowel movement in a couple weeks, and stated he was only having diarrhea. His abdomen was hard, round, and distended, bowel sounds were not active, pain was rated 8 out of 10, and excessive belching was noted. The note was faxed to the physician, but there was no documentation that the on-call physician was contacted directly. The resident’s condition continued to worsen overnight and into the next day. At 1:58 a.m., he was yelling out with abdominal pain and excessive belching, and his abdomen was distended with hypoactive bowel sounds, but there was no documentation that the physician was notified. Later, he developed visible shortness of breath, difficulty finishing sentences, nausea, and a firm, distended abdomen with hypoactive bowel sounds. He was sent to the hospital and admitted for a perforated bowel, small bowel obstruction, and necrosis, underwent surgery, and later died. Interviews with the DON, NP, Unit Manager, and RN 2 confirmed that the physician was not called directly when the resident’s condition worsened and that faxing after hours did not ensure timely notification.
Failure to Provide Written Bed Hold Policy Notice on Transfer
Penalty
Summary
The facility failed to ensure that the resident and/or the resident's representative was provided in writing with the facility's bed hold policy upon transfer for three residents who were hospitalized. Resident 64, who had diagnoses including myocardial infarction, acute pulmonary edema, supraventricular tachycardia, respiratory failure with hypoxia, combined systolic and diastolic congestive heart failure, and type 2 diabetes mellitus, was sent to the ER for increased shortness of breath and later returned after a hospital stay for shortness of breath and CHF exacerbation. There was no documentation in the electronic medical record that the resident or representative received written information about the bed hold policy, including reserve bed payment. Resident 67, with diagnoses including constipation, right fibular fracture, hypertension with heart failure, and chronic anticoagulation, was sent to the ER for shortness of breath, dyspnea, pain, and nausea and was later admitted to the hospital with a perforated bowel. Resident 3, with diagnoses including Parkinson's disease, dementia, morbid obesity, hypertensive chronic kidney disease, and personal history of Covid-19, was sent to the hospital for rectal bleeding, later returned after treatment for hypernatremia and fluid overload, and was again sent to the ER for an ileus pattern and then admitted for a gastrointestinal bleed of unknown origin. For both residents, there was no documentation that the resident or representative was provided written notice of the facility's bed hold policy, including reserve bed payment. The ED stated the bed hold policy and reserve bed cost were not given to the resident's representative in writing, and the Unit Manager stated the bed hold policy form was to be completed with all transfers and copied to go with the resident when transferred.
PASARR Level I Not Completed for New Mental Health Diagnosis and Antipsychotic Use
Penalty
Summary
The facility failed to ensure a PASARR Level I screen was completed when a resident had a new mental health diagnosis and was prescribed an antipsychotic medication. Resident 5’s record showed diagnoses including depressive disorder, anxiety disorder, congestive heart failure, dementia, and hypertension. A physician ordered Rexulti, an atypical antipsychotic, on 11/05/25 related to anxiety disorder, and buspirone was also ordered the same day. The care plan identified the resident as at risk for anxious mood, with behaviors including fidgety, restless, tearful, anxious, and agitated, and included medication administration as an intervention. The PASARR Level I screen related to the anxiety disorder diagnosis and the new medication was not completed until 1/16/26. During interview, the Social Service Director stated that when a resident had a new psychotropic medication or a new mental health diagnosis added, a new Level I needed to be completed, and acknowledged that the resident did not have a new Level I completed until 1/16/26. The facility policy identified psychotropic medication as medication that affects brain activity associated with mental processes and behavior.
Missed Daily Weights for Resident With CHF
Penalty
Summary
The facility failed to ensure daily weights were obtained as ordered for a resident with congestive heart failure, dementia, diabetes mellitus, atrial fibrillation, and an anxiety disorder. A physician order dated 6/28/25 directed staff to obtain a post-void daily weight in the morning before breakfast, while wearing pajamas, and to notify the physician for a 2-pound weight gain in 24 hours or a 5-pound or greater gain in 1 week. Review of the MAR showed multiple missed daily weight entries in October, November, and December 2025, including several dates in each month when the weight was not documented. The record also showed weight gains of 2.8 pounds on 10/27/25, 2.5 pounds on 11/28/25, and 3.5 pounds on 11/30/25. A care plan related to CHF was not located in the electronic medical record. During interviews, CNA 9 stated the nurse told CNAs which resident needed a daily weight and the nurse charted the weight after it was obtained, while LPN 10 stated the nurse added residents with daily weight orders to the CNA assignment clipboard and then entered the weight into the electronic health record. The facility policy titled Daily Weight Monitoring for Residents with Physician Orders stated weights were to be obtained upon arising, before the first meal, in consistent light clothing, and that nursing staff were responsible for obtaining and documenting weights accurately.
Documentation Failures in Medication and Care Monitoring
Penalty
Summary
The facility failed to ensure proper documentation for behavior and side effect monitoring for psychotropic medications, wound care treatments, and catheter care for four residents. Resident 18, diagnosed with dementia and other mental health disorders, had multiple instances where side effect monitoring for antianxiety, antidepressant, and antipsychotic medications was not documented as required by physician orders. Similarly, Resident 33, with Parkinson's disease and mental health issues, also had missing documentation for side effect monitoring of antidepressant and antianxiety medications. Resident 20, who was at risk for pressure ulcers due to impaired mobility, had missing documentation for wound care treatments on several days, despite a physician's order for daily wound care to the right buttock. The Director of Nursing acknowledged that the treatment administration record should have been completed. Resident 12, with an indwelling catheter due to conditions like diabetes and chronic kidney disease, had numerous instances of missing documentation for catheter care across different shifts, as per the physician's order for every shift care. Interviews with nursing staff, including a Registered Nurse and a Licensed Practical Nurse, confirmed that the documentation should have been completed as per the facility's policies. The facility's policies on charting and documentation, psychotropic medication use, and charting errors emphasize the importance of accurate and timely documentation, which was not adhered to in these cases.
Failure to Follow Medication Parameters for Two Residents
Penalty
Summary
The facility failed to ensure that staff adhered to physician-ordered medication parameters for two residents. Resident 45, diagnosed with end-stage renal disease, congestive heart failure, pulmonary edema, and atrial fibrillation, had a physician's order for metoprolol to be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the medication was administered multiple times despite the resident's heart rate and blood pressure being below these parameters. The Director of Nursing acknowledged that the medication should not have been given outside of the specified parameters. Similarly, Resident 33, who had diagnoses including orthostatic hypotension, Parkinson's disease, depression, dementia, and anxiety disorder, was prescribed midodrine to be administered only if the systolic blood pressure was less than 130. Despite this, the medication was given on numerous occasions when the resident's systolic blood pressure exceeded 130. An LPN confirmed that the medication should not have been administered under these conditions, and the DON was unsure why the medication was given. The facility's policies on administering medication and documentation were not followed, leading to these deficiencies.
Delayed Therapy Evaluations and Non-Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure timely completion of therapy evaluations and adherence to physician's orders for two residents, leading to deficiencies in care. Resident 51, who had a history of falls and was at risk for decreased activities of daily living, was observed multiple times in a compromised position in her wheelchair, leaning forward or to the side. Despite a physician's order for physical therapy evaluation and treatment dated 2/4/25, the therapy evaluation was delayed by 17 days, and the resident was only seen after a fall on 2/21/25. The Therapy Director was unaware of the resident's history of leaning and could not explain the delay in therapy evaluation. Resident 9, who had a history of contractures and impaired activities of daily living, also experienced a delay in therapy evaluation. A physician's order for physical and occupational therapy was issued on 2/4/25, but the evaluation was not completed until 2/20/25, 16 days later. The resident's family member reported having to request staff assistance for repositioning, and the resident had a history of wounds on her buttocks. The Director of Nursing and LPN were unable to explain the delay in therapy evaluation, which was supposed to occur within 72 hours of the order. The facility's policies on therapy management and documentation were not followed, as evidenced by the lack of timely therapy evaluations and incomplete documentation in the electronic health records. The facility's policy required therapy evaluations to be conducted promptly upon receiving a physician's order, but this was not adhered to, resulting in a failure to provide necessary care to maintain or improve the residents' range of motion and mobility.
Failure to Implement Dementia Care Interventions for Wandering Residents
Penalty
Summary
The facility failed to provide appropriate person-centered dementia care interventions for two residents, Resident B and Resident C, who exhibited wandering behaviors. Resident B was observed multiple times attempting to exit the facility, triggering alarms, and wandering into other residents' rooms. Despite having a care plan that included a wanderguard to prevent elopement, the facility did not consistently check the wanderguard placement every shift as ordered by the physician. Additionally, behavior management monitoring was not documented for Resident B, indicating a lack of proper oversight and intervention for her wandering behaviors. Resident C, diagnosed with Alzheimer's disease and dementia with psychotic disturbance, also had a care plan that included a wanderguard to prevent unaccompanied exits. However, documentation for checking the wanderguard placement was missing on several occasions across different shifts. Interviews with facility staff, including an LPN and the DON, confirmed that if the monitoring was not documented, it was not performed, highlighting a gap in the facility's adherence to its own policies and procedures. The facility's policies on elopement prevention and documentation were not followed, as evidenced by the lack of consistent monitoring and documentation of the wanderguard checks and behavior management. The facility's failure to ensure these interventions were properly implemented and documented contributed to the deficiency in providing adequate care for residents with dementia and wandering behaviors.
Failure to Conduct Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the pharmacy provided gradual dose reduction (GDR) requests for psychotropic medications for two residents, leading to deficiencies in medication management. Resident 18, diagnosed with dementia, anxiety, depression, and other disorders, was prescribed buspirone, duloxetine, and Zyprexa. The clinical record lacked GDR considerations for buspirone and duloxetine, and did not include the required two GDR considerations for Zyprexa within the specified timeframe. The Director of Nursing confirmed that all available GDR documentation had been provided, indicating a lapse in the facility's adherence to GDR protocols. Similarly, Resident 33, diagnosed with Parkinson's disease, depression, dementia, and anxiety disorder, was prescribed buspirone. The clinical record did not include a GDR consideration for this medication, and a consultant pharmacist's recommendation for a GDR was undated and unsigned by the physician. The Clinical Executive Director acknowledged that it had been over a year since the last GDR for buspirone was conducted. The facility's policy required GDR attempts in two separate quarters within the first year of medication use, and annually thereafter, which was not followed in these cases.
Failure to Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were administered to a resident, identified as Resident B, who was reviewed for immunizations. Resident B's clinical record indicated diagnoses including dementia, polyosteoarthritis, pure hyperglyceridemia, prediabetes, history of falling, and insomnia. Informed consents for both influenza and pneumococcal vaccinations were signed by Resident B's representative on October 9, 2024. However, the immunization report dated February 24, 2025, showed that the resident's last influenza vaccine was administered on September 27, 2023, and she had not received a pneumococcal vaccination. During an interview, the Infection Preventionist (IP) indicated that Resident B had received Tamiflu for influenza exposure at the time of admission, which delayed the influenza vaccination. However, the IP was unaware of why the influenza vaccine was not administered later or why the pneumococcal vaccine was not given at all. The facility's current policies, reviewed on June 25, 2024, stated that influenza vaccines should be offered between October 1st and March 31st, and pneumococcal vaccines should be offered within thirty days of admission. Despite these policies, Resident B did not receive the required vaccinations as per the facility's guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cumberland Pointe Health Campus | 0.3 mi | ★★★★★ | 0 | 0 |
| Heritage Healthcare | 1 mi | ★★★★★ | 7 | 0 |
| University Place Health Center And Assisted Living | 1.4 mi | ★★★★★ | 5 | 0 |
| Indiana Veterans Home | 2 mi | ★★★★★ | 4 | 0 |
| Saint Anthony Rehab And Nursing Center | 2.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.