Westminster Village North
WESTMINSTER VILLAGE NORTH in INDIANAPOLIS, IN — inspection on August 19, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/18/25 at 1:58 p.m., Registered Nurse (RN) 2 indicated, on 7/25/25, Resident B had been found outside of the secured memory care unit unsupervised.
The facility security cameras were reviewed.
The family member of another resident had left and used the handicap button to open the door.
The family member had not paid attention, and Resident B had followed them out at 4:03 p.m.
When staff found Resident B, she told the staff member she needed to go back in the same door she had used to leave.
The family members had been educated, and the door had been changed to close more quickly.
Family members no longer had the codes to the doors and staff were to let them in and out. On 8/18/25 at 3:45 p.m., the exit doors of the secured memory unit were observed with Licensed Practical Nurse (LPN) 3. LPN 3 opened the first exit door of the unit using a code and pushing the handicap accessible button.
The first exit door opened and was observed to stay open for approximately five seconds before beginning to close.
The entry area to the unit had a second door to access the outside.
There was an additional keypad which controlled the second exit door. LPN 3 indicated the second keypad for the exit door to the outdoors had been added after Resident B had eloped.
There was not a wander guard system on the exit doors of the unit. On 8/19/25 at 10:34 a.m., the bench that Resident B was found sitting on was observed with Certified Nurse Aide (CNA) 4.
The bench was located around a half circle corner at the back of the memory care unit, away from the secured memory unit exit doors.
The bench was not visible from the exit doors; however, it was visible from the road which enters the facility campus. CNA 4 indicated, on 7/25/25 at approximately 4:15 p.m., she had driven into the facility campus and saw Resident B sitting on the bench. CNA 4 had recognized Resident B as a resident of the memory care unit and wondered if she was okay. CNA 4 stopped her car and approached Resident B, who was sitting on the bench with a book, and assisted Resident B back to the secured memory care unit and informed the staff on the unit that she had found Resident B outside. On 8/18/25 at 2:47 p.m., the Director of Nursing provided the Elopement Prevention and Intervention Policy, dated 7/26/25, which indicated .It is the policy of Westminster Village to protect vulnerable residents from wandering into unsafe areas or from leaving the facility without appropriate supervision.
Procedure: 1.
Residents admitted with a diagnosis or signs/ symptoms of cognitive impairment will be screened for elopement risk at the time of admission, and with each MDS Assessment .4.
The interdisciplinary team will develop and implement a plan of care to protect residents who are assessed to be at-risk, or otherwise demonstrate exit seeking behavior .This deficient practice was corrected on 8/1/25, prior to the start of the survey, and was therefore past noncompliance.
The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding elopement, evaluated all residents to identity potential residents at risk for elopement, serviced the exit door regarding a keypad code and egress time, and conducted an elopement program evaluation to ensure assessments have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review.This citation relates to Intake 2572780 and Intake 2583098.3.1-45(a)(1)3.1-45(a)(2)
155167 08/19/2025
Westminster Village North 11050 Presbyterian Dr Indianapolis, IN 46236
services of a licensed pharmacist.
received timely from the facility contracted pharmacy and administered, as ordered by the physician,
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)
155167 08/19/2025
Westminster Village North 11050 Presbyterian Dr Indianapolis, IN 46236
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)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.