Cycle 1
Health 2024-07-18 · Fire 2024-07-18
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Indianapolis, IN
Westminster Village North
1-star overall rating with 1-star inspections with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
11050 Presbyterian Dr, Indianapolis, IN
(317) 823-6841
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
129
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Bhi Senior Living
Operator or chain grouping
Approved since
1974-03-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
0.98
Licensed practical nurse staffing
Aide hours / resident day
1.79
Nurse aide staffing
Weekend hours
2.92
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
93.6%
1.9 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
95.4%
3.8 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.8%
2.1 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
24.6%
19 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 11.7% |
5.6%
6.1 pts worse
|
5.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
23.5%
9.3 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
14.8%
3.7 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
13.3%
4.2 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
11.7%
7.3 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
24.2%
2.6 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.1%
0.9 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
81.6%
17 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
10.5%
2.4 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.5% |
79.0%
15.5 pts better
|
79.7%
14.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.4%
1.9 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-24 · Fire 2023-03-24
12 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-03-04 · Fire 2020-03-04
16 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-07-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-07-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-07-18
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-07-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-18
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-01
E · Potential for more than minimal harm
2023-03-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-24
C · Minimal harm
2023-03-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-24
F · Potential for more than minimal harm
2020-03-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-09-16
E · Potential for more than minimal harm
2020-03-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-09-16
E · Potential for more than minimal harm
2020-03-04
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2020-09-16
C · Minimal harm
2020-03-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-08-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-18
D · Potential for more than minimal harm
2024-12-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-07-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-08
E · Potential for more than minimal harm
2024-07-18
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-09-08
E · Potential for more than minimal harm
2024-07-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-08
E · Potential for more than minimal harm
2024-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-08
E · Potential for more than minimal harm
2024-07-18
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 2024-09-08
E · Potential for more than minimal harm
2024-07-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
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 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-02-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-23
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 2024-03-14
E · Potential for more than minimal harm
2023-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-24
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 2023-04-07
D · Potential for more than minimal harm
2023-03-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-24
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 2023-04-07
D · Potential for more than minimal harm
2023-03-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-24
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 2023-04-07
D · Potential for more than minimal harm
2023-03-24
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-07
E · Potential for more than minimal harm
2020-03-04
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 2020-03-04
E · Potential for more than minimal harm
2020-03-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-04
E · Potential for more than minimal harm
2020-03-04
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2020-03-04
E · Potential for more than minimal harm
2020-03-04
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 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-03-04
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 2020-03-04
D · Potential for more than minimal harm
2020-03-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-04
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Gaskins, Chuck
Operational/Managerial Control · Individual
Long, Steven
Operational/Managerial Control · Individual
Long, Steven
Corporate Officer · Individual
Westminster Village North, Inc.
Operational/Managerial Control · Organization
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4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
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1-star overall rating with 1-star inspections with 20 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Clearvista Lake Health Campus
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2-star overall rating with 3-star inspections with 4 recent health deficiencies
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