Westminster Village Muncie INC

Based on observation, interview, and record review, the facility failed to ensure food was 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. Findings include: During a lunch meal service, on 5/6/26 from 11:35 a.m. to 11:40 a.m., the following food service concerns were observed:Cook 5 was wearing disposable gloves. Using her gloved hands, she touched resident meal tickets, clean dishes, scoops, tongs, sweat potato fries, and a sandwich. She repeated this process touching meal tickets, the outside of the bread bag, fries, sandwich wraps, and plate rims. She left the steam table area, and using the same soiled gloves, she took a hot dog out of bag and placed it on an electric griddle. She returned to the food service line, and using her soiled gloved hands, touched meal tickets, plates, sweet potato fries, and wrap sandwiches. She then went over to the grill, and with the same soiled gloves, touched the wrapper on a bag of hot dog buns, removed the bun from the bag, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) and utilize proper hand hygiene during suprapubic catheter (urinary catheter inserted into the bladder via the abdomen) care for 1 of 2 residents reviewed for urinary catheters. (Resident 17)B. Based on observation and interview, the facility failed to properly handle medications utilizing infection prevention and control measures during medication administration for 2 of 4 residents reviewed for medication administration. (Resident 37 and Resident 40)Findings include:A1. During an observation, on 5/6/26 at 11:38 a.m., Resident 17 was in his bed. The urinary catheter drainage bag and tubing were directly against the floor. An EBP sign was hung on the right side of the doorway above the canister of personal protective equipment. The sign indicated everyone must clean their hands before entering and when leaving the room. Providers and staff must wear gloves and a gown for high-contact care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to have a system in place to respond to and promptly resolve resident council concerns. Finding includes: Review of the facility's Resident Council Minutes, on 6/16/25 at 9:36 a.m., included the following Resident Council concerns: On 4/17/25 at 10:30 am., six residents attended the resident council meeting. A concern in the minutes under dietary indicated the hot foods not. The Resident Council Action Form was left blank. The form had areas for the reported concern, date the form was due back to resident council, staff response and action plan, and staff signature and title. On 5/15/25 at 11:00 a.m., seven residents attended the resident council meeting. The Old Business section was left blank. A concern under dietary indicated some residents reported the food was cold sometimes. The minutes lacked a Resident Council Action Form. During an interview on 6/16/25 at 10:03 a.m., Life Enrichment Director 12 indicated she did not have additional follow-up/action information to provide regarding the concerns brought to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide bed hold policy and transfer/discharge notifications to the resident/representative for 2 of 2 residents reviewed for hospitalizations. (Residents 1 & 17) Findings include: 1. Resident 1's clinical record was reviewed on 6/17/25 at 11:41 a.m. Diagnoses included acute on chronic diastolic (congestive) heart failure, hypertensive heart disease with heart failure, and hypertension. A 4/6/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 5/31/25, discharge, MDS assessment indicated the resident discharged with a return anticipated. A 5/31/25, progress note indicated the resident complained of pain in the right upper and lower quadrant of her chest, right side of her back, and under her right shoulder. The pain was getting worse and the resident requested to be sent to the emergency room. The ambulance arrived and all parties were notified. The clinical record lacked indication of whether a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure staff competency regarding narcotic administration and reconciliation for 2 of 3 residents reviewed for narcotic use. The deficiency had potential to impact 11 residents who received narcotic pain medication from the unit medication cart. (Resident 5 and Resident 263) Findings include: During a medication storage observation with LPN 6 on 6/13/25 at 12:58 p.m., the 50s hallway narcotic log indicated Resident 5 received as needed (PRN) doses of tramadol (a narcotic pain medication) on the following dates: 6/4/25 at 10:00 p.m. 6/5/25 at 9:00 p.m. 6/12/25 at 8:30 p.m., and signed by RN 7 6/6/25 at 8:00 p.m. 6/7/25 at 7:00 p.m. 6/8/25 at 7:12 p.m. 6/9/25 at 8:00 p.m. 6/10/25 at 7:30 p.m. 6/11/25 at 6:30 p.m. 6/12/25 at 8:30 p.m. and signed by RN 8 Resident 263 received PRN doses of oxycodone (narcotic pain medication) at the following dates and times: 5/28/25 at 9:44 p.m., 6/7/25 at 8:53 p.m., 6/9/25 at 12:30 a.m., and signed out by RN 8 and on 6/5/25 at 10:34 p.m., signed out by RN 7. Resident 5's clinical record was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure shift to shift narcotic reconciliations were completed to account for controlled medications for 2 of 5 medication carts reviewed for medication storage. ([NAME] Court Unit and Bristol Court Unit) This deficient practice had the potential to affect 21 out of 57 residents who resided in the facility and received controlled medications from [NAME] Court Unit and Bristol Court Unit medication carts. Findings include: 1. During a medication storage observation, accompanied by RN 10 on 6/13/25 at 11:40 a.m., the Narcotic Count Log for [NAME] Court Unit medication cart was reviewed and lacked a count or off-going staff signature when RN 10 took over the cart at the beginning of his shift at 6:00 a.m. on 6/13/25. During an interview on 6/13/25 at 11:51 a.m., RN 10 indicated a shift to shift count had not been completed at the beginning of his shift because the off-going nurse left before the count was completed. Counts and signatures of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) during catheter care for 1 of 3 residents reviewed for EBP. (Resident 255) Finding includes: During an observation on 6/11/25 at 3:49 PM, EBP signage was observed to the left of resident 255's door and indicated the following: Stop. Enhanced barrier precautions. Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. During a catheter care observation on 6/17/25 at 1:17 PM, LPN 5 performed hand hygiene and donned gloves, but not a gown prior to entry into Resident 255's room. She knocked on the door, announced herself, and explained the procedure to the resident. LPN 5 prepared wet and dry wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide safe and secure storage of medications for 17 of 17 residents on the Bristol Unit and to label a multi-use medication vial with an open date for 1 of 4 residents reviewed for medication storage. (Resident 14) During an observation on 5/22/24 at 2:31 p.m., a medication cart was unattended and unlocked in a common area of the unit. At 2:34 p.m., RN 5 approached the cart and confirmed the cart was unlocked. RN 5 indicated it should be locked and contained medications for the residents on the unit only. During a medication administration observation for Resident 14, on 5/23/24 at 9:58 a.m., QMA 6 indicated an open vial of prescription eye drops, Latanoprost 0.005% solution (for glaucoma), did not have an open date on it, but should be dated. She was unsure which types of prescription eyedrops were supposed to be dated upon opening. A current facility policy titled LTC Facility's Pharmacy Services and Procedures Manual, revised on 7/21/22, was provided by the Health Operations Administrator on 5/28/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement the facility's pneumococcal vaccines policy utilizing the Centers for Disease Control and Prevention (CDC) guidelines and failed to offer appropriate pneumococcal vaccinations for 1 of 5 residents reviewed for vaccinations. (Resident 49) Findings include: The clinical record for Resident 49 was reviewed on 5/22/24 at 2:39 p.m. Diagnosis included hypertensive heart disease with heart failure, unspecified chronic atrial fibrillation, and type 2 diabetes mellitus. Resident 49 was over [AGE] years of age. Resident 49's current vaccination record indicated she received the Pneumococcal Conjugate vaccine (PCV) 13 on 3/18/15 and the Pneumococcal Polysaccharide vaccine (PPSV) 23 on 5/22/18. The clinical record lacked indication of any other offered pneumococcal vaccinations. During an interview, on 5/28/24 at 10:10 a.m., RN 3 indicated she only utilized the Children and Hoosiers Immunization Registry Program (CHIRP) for all new residents. The CHIRP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure employees were trained in and knowledgeable of the facility elopement policy and protocol, resulting in a cognitively impaired resident being unsupervised outdoors for 17 minutes (QMA 16). Findings include: Resident B's clinical record was reviewed on 3/5/24 at 10:23 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Her physician orders included check placement of the wanderguard to her left ankle twice daily and check motion sensor for placement by her door and to make sure it was on and worked properly. An admission Minimum Data Set (MDS) assessment, dated 1/10/24, indicated she was severely cognitively impaired. She had a current care plan for psychosocial well-being, as she had the potential to exhibit wandering and exit seeking behaviors (1/12/24). Her interventions included document in the progress notes the intensity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.