Westminster Village North

Based on interview and record review, the facility failed to ensure a newly ordered medication was received timely from the facility contracted pharmacy and administered, as ordered by the physician, for 1 of 3 residents reviewed for unnecessary medications. (Resident E)Findings include: The clinical record for Resident E was reviewed on 8/18/25 at 11:17 a.m.

The diagnoses included, but were not limited to, congestive heart failure. A Quarterly Minimum Data Set assessment, dated 6/9/25, indicated she was severely cognitively impaired. A Skin/Wound Note, dated 7/25/25 at 12:03 p.m., indicated Resident E had swelling present to the left lower extremity and foot.

Upon assessment, Resident E's limb had redness with areas that appeared to be blistering.

The Nurse Practitioner (NP) was notified and would assess.A physician's order, dated 7/25/25 at 1:16 p.m., indicated Resident E was to receive furosemide (a diuretic medication used to help remove excess fluids from the body) 20 milligrams (mg) given twice a day for edema (swelling) for four days. A Health Status Note, dated 7/26/25 at 6:24 a.m., indicated Resident E continued to have edema in left lower extremity with no complaints of pain or discomfort. A Health Status Note, dated 7/26/25 at 11:14 p.m., indicated Resident E continued to have edema in her left lower extremity with redness in both legs.

She had no complaints of pain or discomfort.

The July 2025 Medication Administration Record (MAR) did not contain documentation that the furosemide 20 mg was administered on 7/25/25 in the evening, or 7/26/25 in the morning or in the evening.

The first dose of furosemide 20 mg was documented as being given on 7/27/25 in the morning.

Resident E's clinical record did not contain information that the facility pharmacy had been contacted about the delivery of Resident E's furosemide.

During an interview on 8/19/25 at 11:20 a.m., the DON indicated furosemide 20 mg was available for use in the Emergency Drug Kit at the facility. On 8/19/25 at 12:50 p.m., the Director of Nursing (DON) provided the Packing Slip Proof of Delivery form that indicated Resident E's furosemide 20 mg tablets were delivered to the facility on 7/27/25 at 6:31 p.m.

The facility pharmacy was unavailable for interview.On 8/19/25 at 1:11 p.m., the DON provided the facility pharmacy instructions for ordering and reordering medications which indicated Monday through Friday new orders needed to be received by 7:00 p.m., Eastern Standard Time. On Saturday and Sunday, new orders need to be received by 3:00 p.m., Eastern Standard Time.

During an interview on 8/19/25 at 1:11 p.m., the DON indicated the pharmacy required new orders to be sent to the pharmacy by the listed times to be included in the nightly drug delivery.

She was unsure why Resident E's furosemide had not been delivered until 7/27/25.

There was no documentation available that furosemide 20 mg had been removed from the Emergency Drug Kit machine for Resident E.

This citation relates to Intake 2583098. 3.1-25(a)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westminster Village North

11050 Presbyterian Dr Indianapolis, IN 46236

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was worn during a wound treatment and to ensure hand hygiene was performed after doffing disposable gloves for 1 of 3 residents reviewed for wound care (Resident E).Findings include: The clinical record for Resident E was reviewed on 8/18/25 at 11:17 a.m.

The diagnoses included, but were not limited to, congestive heart failure. A Quarterly Minimum Data Set assessment, dated 6/9/25, indicated she was severely cognitively impaired. A physician's order, dated 8/12/25, indicated to cleanse the area on the top of the right foot with wound cleanser, apply bacitracin to the wound bed, top with xeroform (petroleum gauze), cover with an ABD pad (type of wound dressing), wrap with kerlix (type of wound dressing) and secure with tape. On 8/19/25 at 10:05 a.m., Registered Nurse (RN) 2 was observed providing wound care to Resident E. RN 2 donned disposable gloves and removed the old dressing from Resident E's right foot.

RN 2 went to the bathroom and removed her disposable gloves and applied a new pair. RN 2 did not perform hand hygiene after removing her used disposable gloves. RN 2 then cleansed the wound on the top of Resident E's right foot, applied xeroform gauze and wrapped Resident E's right foot with kerlix, securing the dressing with tape. RN 2 did not don a gown prior to beginning the treatment on Resident E's right foot.

During an interview on 8/19/25 at 10:15 a.m., RN 2 indicated Resident E was in Enhanced Barrier Precautions (EBP) and she would normally wear a gown during a wound dressing change.

Gowns were available on the back of the room door for use.

She would normally perform hand hygiene after doffing a pair of gloves, prior to putting on a new pair of gloves. On 8/19/25 at 1:20 p.m., the Director on Nursing provided the current Enhanced Barrier Precautions Policy that indicated .It is the policy of the facility to ensure that additional and appropriate PPE [Personal Protective Equipment] is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms also known as MDRO's .Who is at 'High Risk' for acquiring or spreading a MDRO .Residents with wounds regardless of MDRO status .Examples of 'High Contact' Resident Care Activities at which time EBP is to be practiced are .Wound Care .Procedure: 1) When engaging in any of the afore mentioned 'High Contact' Resident Care Activities with a resident who has a known MRDO, or a colonized MRDO, or who would be at a high risk to contract a MRDO- use gloves and gowns [EPB] .This includes all required Hand Hygiene before and after donning/doffing gloves and gowns .3.1-18(b)(2)3.1-18(j)

Facility ID: