Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WESTMINSTER VILLAGE NORTH
INDIANAPOLIS, IN · 148 certified beds · Last Life Safety survey November 24, 2025
CMS Certification Number 155167 · first certified March 1974
Ownership
Operated by BHI SENIOR LIVING · Government - County
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IN
33 citations — more than 91% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 19 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was November 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 33 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 33 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 33 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 24, 2023 | 3 |
| July 18, 2024 | 11 |
| November 24, 2025 | 19 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-11-24 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-11-24 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-11-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-11-24 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2024-07-18 |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | 1 | 2025-11-24 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-07-18 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2024-07-18 |
What the citations cover
- Smoke Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Emergency Preparedness Deficiencies 5
- Egress Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Emergency Preparedness Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 24, 2025 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 18, 2026) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (February 18, 2026) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (February 18, 2026) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (February 18, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (February 18, 2026) |
July 18, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 1, 2024) |
March 24, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 24, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 24, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.