Westminster Village North: Medication Delay Violations - IN
The resident, identified in inspection records only as Resident E, had a physician's order written at 1:16 p.m. on July 25, 2025, for furosemide, a diuretic used to pull excess fluid from the body. The dose was 20 milligrams, twice a day, for four days. A nurse had flagged the swelling that morning. A nurse practitioner had assessed her. The order was in the chart.
Nobody gave her the medication that evening.
The next morning, a nursing note recorded that Resident E still had edema in her left lower extremity. That dose wasn't given either. By 11:14 p.m. on July 26, a nurse noted the swelling continued, now with redness in both legs. That evening dose was also skipped.
The first tablet of furosemide reached Resident E on the morning of July 27 — roughly 40 hours after the physician wrote the order.
When federal inspectors arrived at Westminster Village North on August 19, 2025, and reviewed the July medication administration record, the blank spaces for those three missed doses were plain. There was no documentation that anyone at the facility had called the pharmacy to ask where the medication was. There was no note explaining the gap.
The Director of Nursing told inspectors the furosemide had simply not arrived from the contracted pharmacy until July 27, when delivery records showed it came through the door at 6:31 p.m. — after Resident E had finally received her first dose that morning from a different source that nobody had thought to use sooner.
That source was an Emergency Drug Kit kept at the facility for exactly these situations. The Director of Nursing confirmed furosemide 20 mg was available in it. There was no documentation that anyone had pulled the medication from the kit for Resident E during those two days.
The pharmacy's own delivery schedule, which the Director of Nursing handed over to inspectors, showed that new orders placed by 7:00 p.m. on weekdays would be included in the nightly delivery run. July 25 was a Friday. The order was written at 1:16 in the afternoon. The Director of Nursing told inspectors she could not explain why the medication hadn't arrived until two days later.
The pharmacy was not available for interview.
Resident E's quarterly assessment from June 2025 had documented that she was severely cognitively impaired. She could not have flagged the missed doses herself, could not have asked a nurse why her medication hadn't come, could not have called the pharmacy. Nursing notes from both days recorded that she had no complaints of pain or discomfort — an observation that says nothing about what the fluid was doing inside her leg.
Westminster Village North is a continuing care retirement community on Presbyterian Drive on Indianapolis's northeast side. The inspection was conducted in response to a complaint. Inspectors classified the harm level as minimal, or potential for actual harm, and noted the lapse affected one of three residents whose medication records were reviewed.
The citation covers a period when a physician had determined this woman needed a specific medication, twice a day, urgently enough to order it the same afternoon her leg was found swollen and blistering. The facility had the drug on hand. It had an emergency supply specifically for situations where the pharmacy hadn't yet delivered. For nearly two days, neither was used.
Resident E's legs continued to swell. The notes kept recording it. The medication administration record kept showing blank spaces where doses should have been.
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.
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 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 E, had a physician's order written at 1:16 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.