Westminster Village North: Memory Care Elopement - IN
The resident, identified in inspection records only as Resident B, was sitting on the bench with a book. The bench sat around a half-circle corner at the rear of the building, out of sight of the secured unit's exit doors. It was visible from the road that runs through the facility campus. Nobody inside had known she was there.
The aide, CNA 4, approached Resident B at approximately 4:15 p.m. and walked her back inside. Then she told the staff on the unit what she had found.
Resident B had walked out of the secured memory care unit twelve minutes earlier. At 4:03 p.m., a family member visiting another resident had left through the unit's exit door, using the handicap button to open it. The family member hadn't looked back. Resident B followed them out.
When staff found her, she told them she needed to go back in through the same door she had used to leave.
The incident triggered a complaint investigation that federal inspectors completed on August 19, 2025. What they found when they examined the exit doors with a licensed practical nurse raised questions about how the unit had been secured in the first place.
LPN 3 walked inspectors through the exit on August 18. She opened the first door using a code and the handicap button. The door opened and stayed open for approximately five seconds before it began to close. A second door separated that entry area from the outdoors, controlled by an additional keypad. LPN 3 told inspectors that second keypad had been added after Resident B eloped. Before July 25, it had not been there.
There was no wander guard system on the exit doors.
The facility's response after the incident was extensive, at least on paper. A new elopement prevention policy was dated July 26, the day after Resident B was found outside. Staff were trained on elopement protocols. All residents were screened for elopement risk. The exit door was reconfigured so it closed more quickly. Family members lost access to door codes and were required to wait for staff to let them in and out. The second keypad was installed. Care plans were updated. An elopement program evaluation was launched and referred to the Quality Assessment and Assurance Committee.
The Director of Nursing provided inspectors with the new policy on August 18. It stated that Westminster Village's goal was to protect vulnerable residents from wandering into unsafe areas or leaving without supervision, and that residents with cognitive impairment would be screened for elopement risk at admission and at each subsequent assessment.
Inspectors classified the violation as past noncompliance, noting the facility had corrected the deficient practice on August 1, before the survey began. The level of harm was recorded as minimal harm or potential for actual harm. Resident B showed no signs of injury and no signs of psychosocial distress during follow-up.
What the inspection record doesn't resolve is the question of what would have happened if CNA 4 had taken a different route into work, or arrived a few minutes later, or simply not recognized the woman sitting on the bench. The bench was not visible from the unit's exit doors. It was visible from the road. The difference, on July 25, was one employee's commute.
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: 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.
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Last verified: October 15, 2026 · Our methodology
WESTMINSTER VILLAGE NORTH in INDIANAPOLIS, IN was cited for violations during a health inspection on August 19, 2025.
The resident, identified in inspection records only as Resident B, was sitting on the bench with a book.
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.