Cycle 1
Health 2025-04-28 · Fire 2025-04-28
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Terre Haute, IN
Westminster Village Health & Rehab
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1120 E Davis Dr, Terre Haute, IN
(812) 232-7533
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-09-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,094
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.31% · Performance 24.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.56% · Performance 9.18% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 81.05% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.37
Baseline 4.16 hours · Performance 4.04 hours · Measure score 3.37 · Achievement 3.37 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 14.09% · Lower 95% interval 8.81% |
| Discharge to community | 56.96% |
50.57%
6.4 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 51.15% · Lower 95% interval 50.17% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 119 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 47.5% |
53.69%
6.2 pts worse
|
Numerator 38 · Denominator 80 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 30 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 2.52% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 119 · Adjusted rate 2.18% |
| Healthcare-associated infections requiring hospitalization | 9.18% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 12% · Lower 95% interval 6% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 38.75% |
56.45%
17.7 pts worse
|
Numerator 31 · Denominator 80 |
| Transfer of health information to provider | 93.44% |
95.95%
2.5 pts worse
|
Numerator 57 · Denominator 61 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 20 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.7% |
93.6%
12.9 pts worse
|
93.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 70.8% · Q4 61.1% · 4Q avg 80.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
95.4%
2.5 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
24.6%
22.3 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.2% · Q3 2.4% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 13.6% |
5.6%
8 pts worse
|
5.4%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 18.8% · Q3 17.1% · Q4 7.7% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
23.5%
3.4 pts better
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 21.2% · Q3 19.4% · Q4 15.4% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
14.8%
3.3 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.4% · Q3 11.1% · Q4 16.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
13.3%
10.3 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
11.7%
4.2 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 18.2% · Q4 5.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.2%
1 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 2.1% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.7% |
24.2%
6.5 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 33.8% · Q3 44.6% · Q4 23.8% · 4Q avg 30.7% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
4.1%
4.4 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.9% · Q3 10.5% · Q4 8.5% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.7% |
81.6%
5.9 pts worse
|
81.7%
6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.9% · Q2 82.2% · Q3 62.9% · Q4 70.1% · 4Q avg 75.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
10.5%
0.3 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
79.0%
6 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.4%
1.7 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 21.6% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-27 · Fire 2024-03-27
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-18 · Fire 2023-01-18
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2025-04-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-09
E · Potential for more than minimal harm
2024-03-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-03-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-03-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-09
F · Potential for more than minimal harm
2023-01-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-18
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-28
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-03-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-09
E · Potential for more than minimal harm
2024-03-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-23
D · Potential for more than minimal harm
2023-01-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-27
C · Minimal harm
2023-01-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-27
Penalties and ownership
What sits behind the stars
Ownership
Rush Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Aulbach, Kenny
Corporate Director · Individual
Bacon, Mark
Corporate Director · Individual
Burkett, Kipland
Corporate Director · Individual
Byrne, John
Corporate Director · Individual
Jarman, Ronald
Corporate Officer · Individual
Kinder, Ashley
Corporate Officer · Individual
Matthews, Colleen
Operational/Managerial Control · Individual
Mohr, Gerald
Corporate Director · Individual
Smith, Bradley
Corporate Officer · Individual
Spurlin, Mark
Corporate Director · Individual
Westminster Village Terre Haute Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Southwood Healthcare Center
Terre Haute, IN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $14,518 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Springhill Village
Terre Haute, IN
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Westridge Health Care Center
Terre Haute, IN
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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