Westminster Village North: Infection Control Failures - IN
The August 19 inspection at Westminster Village North found that Registered Nurse 2 failed to follow enhanced barrier precautions while providing wound care to Resident E, a woman with severe cognitive impairment and congestive heart failure.
Federal inspectors observed the nurse at 10:05 a.m. as she removed an old dressing from the resident's right foot. She walked to the bathroom, removed her disposable gloves, and put on a new pair without washing her hands. The nurse then cleaned the wound, applied petroleum gauze, and wrapped the foot with kerlix dressing.
Throughout the procedure, she never put on a gown.
Ten minutes later, when questioned by inspectors, the nurse acknowledged that Resident E was under Enhanced Barrier Precautions and that she "would normally wear a gown during a wound dressing change." Gowns were available on the back of the room door. She also admitted she "would normally perform hand hygiene after doffing a pair of gloves, prior to putting on a new pair of gloves."
The resident's physician had ordered specific wound care for the top of her right foot five days earlier: cleanse with wound cleanser, apply bacitracin, cover with xeroform gauze and an ABD pad, wrap with kerlix, and secure with tape.
Westminster Village North's own Enhanced Barrier Precautions Policy, provided by the Director of Nursing that afternoon, explicitly requires additional protective equipment "to prevent the spread of Multidrug-resistant Organisms." The policy identifies residents with wounds as "high risk" for acquiring or spreading these dangerous organisms, regardless of their infection status.
The facility's written procedure mandates that staff "use gloves and gowns" during wound care for any resident "who has a known MRDO, or a colonized MRDO, or who would be at a high risk to contract a MRDO." The policy specifically includes "all required Hand Hygiene before and after donning/doffing gloves and gowns."
Wound care appears as a prime example of "High Contact Resident Care Activities" requiring enhanced barrier precautions in the facility's policy.
The infection control violation occurred during a complaint inspection, suggesting someone had raised concerns about practices at the facility. Federal inspectors reviewed wound care procedures for three residents and found failures in one case.
Enhanced barrier precautions represent a critical defense against multidrug-resistant organisms, which pose particular dangers in nursing home settings where vulnerable residents live in close quarters. These protocols require strict adherence to prevent contamination that could spread life-threatening infections throughout a facility.
Hand hygiene between glove changes prevents cross-contamination when healthcare workers move between different areas of a patient's body or handle contaminated materials. The failure to wash hands after removing soiled gloves and before donning clean ones creates a direct pathway for spreading infectious organisms.
Gowns provide an additional barrier during high-risk procedures like wound care, protecting both the healthcare worker's clothing and preventing the transfer of organisms to other residents or surfaces.
The nurse's acknowledgment that she knew the proper procedures but failed to follow them suggests the violation resulted from cutting corners rather than lack of knowledge. Her admission that gowns were readily available eliminates equipment shortage as a potential explanation.
Resident E's severe cognitive impairment made her particularly vulnerable to the consequences of improper infection control. Patients with dementia often cannot communicate symptoms of infection or understand instructions to prevent its spread.
The facility's own policy recognizes that all residents with wounds face heightened risk for multidrug-resistant organisms, making adherence to protective protocols essential regardless of a patient's known infection status.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm," but infection control breaches can have cascading effects throughout nursing home populations. A single lapse in protocol during wound care can introduce dangerous organisms that spread rapidly among vulnerable residents.
The inspection found that Westminster Village North had written policies that met federal standards but failed in the critical area of implementation. Having protective equipment available and policies on paper means nothing when staff ignore basic safety procedures during direct patient care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Village North from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
WESTMINSTER VILLAGE NORTH in INDIANAPOLIS, IN was cited for violations during a health inspection on August 19, 2025.
Federal inspectors observed the nurse at 10:05 a.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.