Westminster Village Kentuckiana: Narcotic Oversight Failure - IN
The resident, identified in inspection records only as Resident C, had a physician's order dated June 20, 2025, for oxycodone with acetaminophen, 7.5 milligrams, every four hours as needed for pain. The order was legitimate. What followed was not.
Between July 31 and August 28, Qualified Medication Aide 10 administered the narcotic on 22 separate occasions, including multiple overnight doses given hours apart. On August 10 alone, the resident received doses at 12:30 a.m., 4:00 a.m., and 8:00 p.m. The same pattern repeated across more than a dozen other dates. The controlled drug record showed QMA 10's name each time. It showed no licensed nurse's signature. Ever.
Inspectors reviewing the clinical record on September 3 found no resident assessment by a licensed nurse tied to any of those administrations. No documentation that a nurse had been contacted. No record that symptoms were described, permission was granted, or that anyone with a nursing license had been involved in the decision to hand a resident a controlled narcotic in the middle of the night.
The facility's own policy made the requirements explicit. The Director of Nursing handed inspectors a document titled Qualified Medication Aide Scope of Practice during the survey. It spelled out that a QMA may administer a PRN medication only if a licensed nurse authorizes it first. The QMA must document the resident's symptoms and when they occurred, document that a nurse was contacted and gave permission, and obtain that permission each time the symptoms occur. The nurse who gave permission must co-sign the controlled drug record before the end of her shift.
None of that happened. Not once across 22 doses.
The aide who administered the medication knew the rules. During an interview on September 4, QMA 5, a different aide, told inspectors that a licensed nurse must assess the resident when a PRN narcotic is requested and must co-sign the controlled drug record alongside the QMA. That understanding was apparently shared knowledge at the facility. It just wasn't practice.
What the inspection report does not explain is how 22 administrations of a controlled substance moved through a facility's recordkeeping over six weeks without a co-signature triggering any internal review. Controlled drug logs exist precisely because opioids require accountability at every step. A column left blank once might be an oversight. A column left blank 22 times across nearly a month is a system that wasn't working.
The inspection, conducted as a complaint survey, was completed September 4, 2025. CMS rated the violation at the level of minimal harm or potential for actual harm. The finding applied to one of three residents reviewed for quality of care.
Resident C's diagnoses included fibromyalgia, depression, and pain. The inspection report does not say whether the resident experienced any adverse effects from the medication. It does not say whether anyone at the facility noticed the missing signatures before inspectors arrived. It does not say whether QMA 10 was ever told the process was wrong.
What it says is that a resident in chronic pain received opioids on 22 nights and mornings, and not once did a nurse document that she had listened to that resident describe their symptoms, weighed whether the medication was appropriate, and put her name next to the decision.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Village Kentuckiana from 2025-09-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
WESTMINSTER VILLAGE KENTUCKIANA in CLARKSVILLE, IN was cited for violations during a health inspection on September 4, 2025.
On August 10 alone, the resident received doses at 12:30 a.m., 4:00 a.m., and 8:00 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.