Westminster Village - West Lafayette

Based on interview and record review, the facility failed to ensure the resident and/or resident's representative was provided in writing the facility's bed hold policy upon transfer for 3 of 3 residents reviewed for hospitalization. (Resident 64, 67 and 3)Findings include:1. The clinical record for Resident 64 was reviewed on 1/15/26 at 9:57 a.m. The diagnoses included, but were not limited to, myocardial infarction, acute pulmonary edema, supraventricular tachycardia, respiratory failure with hypoxia, combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus. A nursing progress note, dated 9/21/25 at 10:45 p.m., indicated the resident was sent to the emergency room for increased shortness of breath. A nursing progress note, dated 9/25/25 at 4:18 p.m., indicated the resident returned to the facility after a hospital stay for shortness of breath and exacerbation of congestive heart failure. There was no documentation in the electronic medical record to indicate the resident or resident's representative was provided with information in…

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 a PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Residents 5)Findings include:The clinical record for Resident 5 was reviewed on 1/15/26 at 12:27 p.m. The diagnoses included, but were not limited to, depressive disorder, anxiety disorder, congestive heart failure, dementia, and hypertension.A physician's order, dated 11/05/25, indicated to administer Rexulti (an atypical antipsychotic medication) 0.5 mg (milligram) one tablet in the morning related to anxiety disorder. A physician's order, dated 11/05/25, indicated to administer buspirone (an anxiolytic medication) 0.5 mg (milligram) one tablet two times a day. A care plan, dated as revised 12/18/25, indicated the resident was at risk for anxious mood as evidenced by becoming fidgety, restless, tearful, anxious, and agitated. The interventions included, but were not limited to, administering medication as…

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 daily weights were obtained as ordered by the physician for 1 of 1 resident reviewed for quality of care. (Resident 9)Findings include: The clinical record for Resident 9 was reviewed on 1/15/26 at 11:33 a.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), dementia, diabetes mellitus, atrial fibrillation, and anxiety disorder.A physician's order, dated 6/28/25, indicated to obtain a post void daily weight in the morning, before breakfast, while wearing pajamas, and to notify the physician if the resident had a two (2) pound weight gain in 24 hours or a five (5) pound or more weight gain in one (1) week. a. The Medication Administration Record (MAR), dated 10/1/25 to 10/31/25, indicated the daily weights were not documented on 10/10/25, 10/18/25, 10/22/25, and 10/29/25.On 10/27/25, Resident 9 had a weight gain of 2.8 pounds.b. The MAR, dated 11/1/25 to 11/30/25, indicated the daily weights were not documented on 11/5/25, 11/7/25, 11/12/25, and 11/25/25.On 11/28/25, Resident 9 had 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 behavior and side effect monitoring for psychotropic medications, wound care treatments, and catheter care were documented for 4 of 4 residents reviewed for documentation. (Resident 18, 33, 20 and 12) Findings include: 1. The clinical record for Resident 18 was reviewed on 2/24/25 at 10:17 a.m. The diagnoses included, but were not limited to, dementia with anxiety, mood disturbance, psychotic disturbance, anxiety disorder, depression, and delusional disorder. A physician's order, dated 2/15/24, indicated to monitor for side effects of antianxiety medication three times a day. a. The Medication Administration Record (MAR), dated 1/2025, indicated antianxiety medication side effect monitoring was not documented each shift on 1/1/25, 1/9/25, 1/12/25, 1/24/25 and 1/29/25. b. The MAR, dated 2/2025, indicated anti-anxiety medication side effect monitoring was not documented each shift on 2/16/25 and 2/18/24. A physician's order, dated 2/15/24, indicated to monitor side effects of antidepressant medication three times 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 followed the physician's ordered medication parameters were followed for 2 of 5 residents reviewed for quality of care. (Residents 45 and 33) Findings include: 1. The clinical record for Resident 45 was reviewed on 2/24/25 at 11:46 a.m. The diagnoses included, but were not limited to, end stage renal disease, congestive heart failure, pulmonary edema and atrial fibrillation. A care plan, dated 7/17/24, indicated Resident 45 had a diagnosis of congestive heart failure and chronic end stage renal failure. Interventions included, but were not limited to, give medications as ordered. A physician's order, dated 7/22/24, indicated to give metoprolol (a blood pressure medication) 12.5 milligrams (mg) twice daily with instructions to hold the medication for a systolic blood pressure of less than 100 or a heart rate of less than 60. The Medication Administration Record (MAR), dated 11/1/24 through 11/30/24, indicated metoprolol was administered: a. On 11/7/24, in the morning with a heart rate of 56. b. On 11/15/24, in…

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 ensure physician's orders were followed and therapy evaluations were completed in a timely manner for 2 of 4 residents review for position and mobility. (Resident 51 and 9) Findings include: During an observation, on 2/19/25 at 12:09 p.m., Resident 51 was in the dining room with her wheelchair pushed away from the table. The resident was leaning forward with her left arm dangling below the wheelchair seat. During an observation, on 2/19/25 at 3:08 p.m., the resident was sitting next to the nurse's station with her eyes closed. The resident was leaning forward and sitting crooked in her wheelchair. During an observation, on 2/20/25 at 10:27 a.m., the resident was sitting next to the nurse's office in her wheelchair. The resident was leaning forward trying to touch her left shoe. The nurse was sitting at the desk in the nurse's office with her back facing the resident and the Certified Nursing Assistant (CNA) was assisting residents out of the dining room. During an observation, on 2/21/25 at 10:49 a.m., the…

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 ensure staff initiated new person-centered dementia care interventions for residents with wandering behaviors and to check wanderguard placement for 2 of 5 residents reviewed for dementia care. (Resident B and C) Findings include: 1. During an observation, on 2/19/25 at 1:35 p.m., Resident B was walking in the common area near the exit doors. During an observation, on 2/20/25 at 12:15 p.m., the resident was ambulating down the hall towards the exit doors. During an observation, on 2/21/25 at 1:54 p.m., the resident was ambulating back from the exit door on her unit. During an observation, on 2/24/25 at 9:06 a.m., the resident was sitting on the couch in the common area in front of the main entrance doors. During an observation, on 2/25/25 at 12:15 p.m., the resident was walking near the front entrance frequently looking at the doors. During an observation, on 2/25/25 at 2:05 p.m., the resident triggered the alarm on an exit door multiple times. The staff were redirecting her away from the door, but she…

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 the pharmacy provided gradual dose reduction (GDR) requests to reduce or discontinue psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 18, and 33) Findings include: 1. The clinical record for Resident 18 was reviewed on 2/24/25 at 10:17 a.m. The diagnoses included, but were not limited to, dementia with anxiety, mood disturbance, psychotic disturbance, generalized anxiety disorder, depression, and delusional disorder. a. A physician's order, with an original start date of 11/15/23, indicated to give buspirone (a medication used to treat anxiety) 10 milligrams (mg) three times per day. The clinical record did not include a GDR consideration for buspirone. The facility was unable to provide a GDR consideration for buspirone. b. A physician's order, with an original start date of 11/15/23, indicated to give duloxetine (a medication used to treat depression) 60 mg each day. A consultant pharmacist physician recommendation form, dated 5/16/24, indicated it was time to consider…

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 influenza and pneumococcal vaccinations were provided for 1 of 5 residents reviewed for immunizations. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/21/25 at 1:54 p.m. The diagnoses included, but were not limited to, dementia, polyosteoarthritis, pure hyperglyceridemia, prediabetes, history of falling, and insomnia. An Informed Consent for Influenza Immunization, dated and signed on 10/9/24 at 4:43 p.m., indicated Resident B's representative gave permission for the influenza vaccination. An Informed Consent for Pneumococcal Immunization, dated and signed on 10/9/24 at 4:43 p.m., indicated Resident B's representative gave permission for the pneumococcal vaccination. An Immunization Report, dated 2/24/25, indicated the resident's last influenza vaccine was given on 9/27/23 and she had not received a pneumococcal vaccination. During an interview, on 2/25/25 at 4:20 p.m., Infection Preventionist (IP) 3 indicated the resident had received Tamiflu for an influenza exposure at the time…

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.

4. During an observation, on 1/23/24 at 12:31 p.m., Resident 25 was observed, in her wheelchair, wearing open toe sandals with a small bandage on her left great toe. During an observation, on 1/26/24 at 11:17 a.m., the resident was sitting up, in her wheelchair, she had sandals on, and a small bandage was noted on her left great toe. The bandage was not dated and had some red drainage present. The clinical record for Resident 25 was reviewed on 1/26/24 at 10:50 a.m. The diagnosis included, but were not limited to, Alzheimer disease, type 1 diabetes mellitus with diabetic neuropathy, bell's palsy, osteoarthritis, and venous insufficiency. A physician's order, dated 1/18/24, indicated the resident may be seen by a wound doctor. A podiatrist note, dated 1/18/24, indicated the resident had non palpable pulses in her bilateral feet and edema was noted. The feet were dry, cool, rubor (red), and her nails were long, moderately thick, and discolored. There was no documentation of bleeding, or a small bandage being applied. A review of Resident 25's nursing progress notes, from 1/20/24 to…

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 a resident received mouth care twice daily for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident 37) Finding includes: During an interview, on 1/22/24 at 2:22 p.m., Resident 37's wife indicated the resident had full upper dentures and a partial bottom denture anchored to his remaining natural teeth. The staff would forget to brush his teeth, the toothbrush was dry when she checked it, and she had observed food and debris on natural teeth. The clinical record for Resident 37 was reviewed on 1/24/24 at 10:38 a.m. The diagnoses included, but were not limited to, hemiplegia (paralysis affecting one side of the body) following cerebral infarction, Alzheimer's disease, dysarthria (slurred speech) following cerebral infarction, and dysphagia (difficulty swallowing) following cerebral infarction. A care plan, dated 10/14/21, indicated the resident had a need for dental care related to having some permanent teeth, a lower partial, and full upper denture. The approaches included, but were not…

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 all areas of the wireless call system were functioning properly for 2 of 2 residents reviewed for call devices. (Residents 19 and 13) Findings include: 1. During an interview, on 1/22/24 at 1:14 p.m., Resident 19 indicated sometimes call lights were not answered or could take a long time to be answered. He used his call pendant around his neck as his call light. During an observation and interview, on 1/22/24 at 1:45 p.m., Resident 19 pressed his call pendant around his neck. During an observation and interview, on 1/22/24 at 1:56 p.m., RN 2 indicated she did not know the resident's call light was pressed. She did not have a notification to her Vocera (wireless communication system staff members wore to receive call light notifications and talk to other staff). There was no indication the resident's call light was pressed per the call light monitor screen out in the hall. During an interview, on 1/22/24 at 1:58 p.m., RN 2 indicated…

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 ensure items were not stored on the floor in resident rooms, carpet squares edges were not peeling, and the walls were free of gouges for 4 of 4 rooms reviewed for environment. (Room A10, A9, A3 and C11D.) Findings include: 1a. During an observation, on 1/22/24 at 10:30 a.m., Room A10 had a small pile of magazines, two decorative boxes, and opened mail on the floor. 1b. During an observation, on 1/25/24 at 12:20 p.m., Room A10 had a large cardboard box with papers inside and opened mail stored on the floor. 2. During an observation, on 1/22/24 at 10:36 a.m., Room A9 had a grocery sack with the resident's personal items on the floor next to the window. 3. During an observation, on 1/22/24 at 2:51 p.m., Room A3 had four squares of carpet peeling up in the center of the four squares. 4. During an observation, on 1/22/24 at 3:49 p.m., Room C11D had a large area of gouges in the drywall and missing paint. During an interview, on 1/22/24 at 12:20 p.m., Certified Nurse Aide (CNA) 6 indicated the sack on the floor 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.