Westminster Village Kentuckiana
Inspection Findings
F-Tag F0602
F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
8/18/25 the pain medication had not arrived. RN 7 called the pharmacy and was advised the medication was sent to the facility on 8/16/25 and was signed by a facility staff member. RN 7 asked the pharmacy if
they could send over a copy of the requisition on who had signed for the narcotic pain medication. The pharmacy sent over the requisition which was signed in by LPN 6. When RN 7 discovered the resident's medication was missing, she then notified the Director of Nursing that somewhere between Saturday night, 8/16/25 and Sunday morning, 8/17/25, Resident B's narcotic pain medication disappeared.During a telephone interview, on 9/4/25 at 10:00 a.m., LPN 8 indicated on the morning of Sunday, 8/17/25, when she arrived to work, LPN 9 asked her to count the narcotics with her so she could leave. LPN 8 and LPN 9 counted the narcotics in the medication cart and the residents' medication cards and sheet counts were correct.During an interview, on 9/3/25 at 12:02 p.m., the Director of Nursing (DON) indicated she was notified by RN 7 about the missing narcotic pain medication for Resident B. The DON initiated an investigation and requested a drug screen for QMA 5, LPN 6, RN 7, LPN 8, and LPN 11, which were all negative. LPN 9 had refused the drug screen via text message. On 9/2/25 at 10:22 a.m., the Director of Nursing provided a current copy of the document titled Resident Rights dated 12/2016. It included, but was not limited to, Policy Interpretation and Implementation .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .be free from .misappropriation of property The Past noncompliance began on 8/16/25. The deficient practice was corrected by 8/20/25 after the facility implemented a systemic plan that included the following actions: A 30-day look back narcotic audit was completed on all residents (8/18/25); All nursing staff were educated
on abuse and misappropriation of resident property (8/19/25); The facility Implemented a narcotic count the count sheet (8/19/25); Drug screens were completed (8/20/25).This Citation relates to Intakes 2579876 and 2597024.3.1-28(a)
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Village Kentuckiana
2210 Greentree N Clarksville, IN 47129
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to ensure an assessment was completed by a licensed nurse and authorization given to administer an as needed narcotic pain medication by a qualified medication aide for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical
record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnoses included, but were not limited to, fibromyalgia, depression and pain.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen (narcotic pain medication) 7.5 mg (milligrams) every 4 hours as needed for pain.The August controlled drug record indicated the resident received the as needed pain medication on the following dates and times by Qualified Medication Aide (QMA) 10: 7/31/25 at 8:00 p.m., 8/01/25 at 12:00 a.m. and 4:00 a.m., 8/09/25 at 9:15 p.m., 8/10/25 at 12:30 a.m., 4:00 a.m. and 8:00 p.m., 8/11/25 at 12:00 a.m. and 4:00 a.m., 8/13/25 at 9:00 p.m., 8/14/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m., 8/15/25 at 12:00 a.m. and 4:00 a.m., 8/20/25 at 8:00 p.m., 8/21/25 at 12:00 a.m. and 4:00 a.m., 8/23/25 at 8:00 p.m., 8/24/25 at 12:00 a.m. and 4:00 a.m., 8/27/25 at 8:00 p.m., and 8/28/25 at 12:00 a.m. and 4:00 a.m.The clinical record lacked a resident assessment, by a licensed nurse, for the as needed pain medication and an authorized signature on the controlled drug record.During an interview, on 9/4/25 at 10:15 a.m., QMA 5 indicated a licensed nurse must assess the resident when the need for the as needed narcotic pain medication was requested and co-sign with the QMA on the controlled drug record.On 9/3/25 at 3:15 p.m., the Director of Nursing provided a current, undated copy of the document titled Qualified Medication Aide Scope of Practice. It included, but was not limited to, The following tasks are within the scope of practice for the QMA unless prohibited by facility policy .Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following .Document in the resident record symptoms indicating the need for the medication and the time the symptoms occurred .Document in the resident
record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact .Obtain permission to administer the medication each time the symptoms occur in the resident .Ensure that the resident's record is cosigned by
the licensed nurse who gave permission by the end of the nurse's shift This Citation relates to Intake 26031163.1-37
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Village Kentuckiana
2210 Greentree N Clarksville, IN 47129
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on interview and record review, the facility failed to ensure a resident's (Resident C) medication administration record accurately reflected the administration of narcotic pain medication for 1 of 3 residents reviewed for documentation.Findings include: The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnosis included, but was not limited to, fibromyalgia.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen, 7.5 mg (milligrams) every 4 hours as needed for pain.The August 2025 controlled drug record indicated the resident received
the medication on the following dates and times:-8/02/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/03/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/08/25 at 10:00 p.m.-8/09/25 at 2:00 a.m., 6:00 a.m., 10:15 a.m., 2:15 p.m. and 9:15 p.m.-8/10/25 at 12:30 a.m. and 12:00 p.m.-8/11/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/12/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/13/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m. and 9:00 p.m.-8/14/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/15/25 at 12:00 a.m., 12:00 p.m. and 8:00 p.m.-8/16/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/17/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/18/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 6:00 p.m. and 10:00 p.m.-8/19/25 at 12:00 a.m., 6:00 a.m. and 8:00 p.m.-8/20/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m.-8/21/25 at 12:00 a.m., 8:00 a.m. and 8:00 p.m.-8/22/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/23/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/24/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/25/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/26/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/27/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.08/28/25 at 12:00 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m.The August 2025 medication administration record for Resident C lacked documentation of the administration of the narcotic medication on the above dates and times.During
an interview, on 9/4/25 at 2:18 p.m., Licensed Practical Nurse (LPN) 12 indicated when a resident's as needed pain medication was administered, the medication should be signed out on the controlled drug
record and the medication administration record.On 9/4/25 at 12:24 p.m., the Director of Nursing provided a current copy of the document titled Documentation of Medication Administration dated 4/2007. It included, but was not limited to, The facility shall maintain a medication administration record to document all medications administered .A Nurse or Certified Medication Aide .shall document all medications administered to each resident on the resident's medication administration record .Administration of medication must be documented immediately after (never before) it is given .Documentation must include .Signature and title of the person administering the medication This Citation relates to Intake 2603116 3.1-50(a)(2)
Event ID:
Facility ID:
If continuation sheet
WESTMINSTER VILLAGE KENTUCKIANA in CLARKSVILLE, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLARKSVILLE, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTMINSTER VILLAGE KENTUCKIANA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.