Cycle 1
Health 2025-02-25 · Fire 2025-02-25
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
West Lafayette, IN
Westminster Village - West Lafayette
5-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2741 N Salisbury St, West Lafayette, IN
(765) 463-7546
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
61
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.82
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
5.39
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.95
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
5.71
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,715
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.52
Composite VBP score used to determine payment impact.
Payment multiplier
1.0094
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 15.38% · Performance 22.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.01
Baseline 4.59% · Performance 6.64% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Total nurse turnover
7.80
Baseline 40.91% · Performance 31.82% · Measure score 7.80 · Achievement 7.80 · Improvement 5.16
Adjusted total nurse staffing
10
Baseline 4.94 hours · Performance 6.01 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.18% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 190 · Observed rate 11.05% · Lower 95% interval 8.89% |
| Discharge to community | 65.79% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 178 · Observed rate 67.98% · Lower 95% interval 60.06% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 108 · Denominator 110 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 110 |
| Discharge self-care score | 44.21% |
53.69%
9.5 pts worse
|
Numerator 42 · Denominator 95 |
| Discharge mobility score | 75.79% |
50.94%
24.9 pts better
|
Numerator 72 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 2.73% |
2.29%
0.4 pts worse
|
Numerator 3 · Denominator 110 · Adjusted rate 2.71% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 4.2% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 286 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 77.89% |
56.45%
21.4 pts better
|
Numerator 74 · Denominator 95 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.44% |
96.28%
2.2 pts better
|
Numerator 63 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 54% |
25.2%
28.8 pts better
|
Numerator 27 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
93.6%
5.4 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.0% |
3.8%
7.2 pts worse
|
3.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 13.8% · Q3 9.8% · Q4 6.2% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
24.6%
16.1 pts better
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 10.9% · Q3 9.8% · Q4 4.3% · 4Q avg 8.5% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.6%
2.7 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.1% · Q3 0.0% · Q4 3.1% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
23.5%
3.8 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 30.0% · Q3 25.0% · Q4 27.3% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
14.8%
0.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.9% · Q3 17.9% · Q4 14.3% · 4Q avg 15.0% · 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 | 24.7% |
13.3%
11.4 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 23.1% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.3% |
11.7%
16.6 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 28.2% · Q3 20.0% · Q4 31.2% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.4%
1.4 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.3% · Q3 2.6% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.2% |
24.2%
10 pts worse
|
19.8%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 43.0% · Q3 28.3% · Q4 25.8% · 4Q avg 34.2% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.1%
1.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.5% · Q3 4.8% · Q4 3.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
81.6%
11.4 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 96.8% · Q3 100.0% · Q4 84.3% · 4Q avg 93.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
10.5%
0.8 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 9.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
79.0%
16.2 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
22.4%
5.6 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 13.0% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
5 health deficiencies
Top issue: Environmental (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-25
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-10
F · Potential for more than minimal harm
2024-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-01-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-18
F · Potential for more than minimal harm
2022-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-05
F · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-25
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 2025-03-20
D · Potential for more than minimal harm
2025-02-25
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 2025-03-20
D · Potential for more than minimal harm
2025-02-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-20
E · Potential for more than minimal harm
2024-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
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 2024-02-29
D · Potential for more than minimal harm
2024-01-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-29
C · Minimal harm
2024-01-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-04-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-01
E · Potential for more than minimal harm
2022-11-03
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 2022-12-14
D · Potential for more than minimal harm
2022-11-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
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 2022-12-14
D · Potential for more than minimal harm
2022-11-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-14
Penalties and ownership
What sits behind the stars
Ownership
Westminster Village West Lafayette, Inc
5% Or Greater Direct Ownership Interest · Organization
Bartholomew, Richard
Corporate Director · Individual
Bartholomew, Richard
Corporate Officer · Individual
Blankenship, Benjamin
Operational/Managerial Control · Individual
Branch Banking & Trust Company
5% Or Greater Mortgage Interest · Organization
Deno, Brad
Corporate Director · Individual
Deno, Brad
Corporate Officer · Individual
Dodt, Keven
Operational/Managerial Control · Individual
Gentry, Don
Corporate Director · Individual
Li, William
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Long, Stephanie
Corporate Officer · Individual
Patz, Kristin
Operational/Managerial Control · Individual
Rose, Marianne
Corporate Director · Individual
Rose, Marianne
Corporate Officer · Individual
Smith, Jane
Corporate Director · Individual
Smith, Jane
Corporate Officer · Individual
Sullivan, Agnes
Corporate Officer · Individual
Tashjian Gibbs, Marcella
Corporate Officer · Individual
Thomas, John
Operational/Managerial Control · Individual
Wilson, Anna
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Cumberland Pointe Health Campus
West Lafayette, IN
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Heritage Healthcare
West Lafayette, IN
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
University Place Health Center And Assisted Living
West Lafayette, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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