ATLANTA, GA - A May 2025 federal inspection at Westminster Commons nursing home documented multiple substantiated cases of resident abuse and neglect, including a sexual abuse incident involving a cognitively impaired female resident, staff refusal to provide care to a quadriplegic resident, and failures to properly report and investigate abuse allegations.
Quadriplegic Resident Left Without Care for Hours
One of the most significant findings involved a substantiated case of neglect against a resident with severe physical limitations. The resident, identified in the report as R136, was admitted in October 2024 with diagnoses including functional quadriplegia, cervical spinal cord injury, and contractures affecting all four extremities.
According to the inspection narrative, R136 was assessed as cognitively intact but completely dependent on staff for all activities of daily living. On March 6, 2025, at approximately 2:00 AM, R136 called requesting assistance to be repositioned in bed. The Registered Nurse on duty asked the assigned Certified Nursing Assistant (CNA 48) to provide the care.
The CNA refused. When interviewed during the facility's investigation, the staff member admitted "she did not go in until 6:30 AM as she felt the resident was rude."
R136 told surveyors: "The CNA came into my room. I asked her who my aide was. She said she was. I told her nobody came into my room to turn me. She told me that I would have to wait until the next shift."
The inspection revealed that approximately four and a half hours passed before R136 received assistance. During the investigation, the facility substantiated the allegation of neglect against the CNA. However, surveyors determined the investigation was incomplete because it failed to examine why the Registered Nurse on duty also did not assist the resident during those hours.
When asked why she did not help R136, the nurse stated: "I was busy with my work. I asked [the CNA] and she told me she wasn't going to do it. I had my own work to do."
The Director of Nursing acknowledged the oversight, stating: "I agree it would be neglect on part of the nurse too. We did not focus on why the nurse did not go into the resident's room to turn him. We were more focused on why the CNA didn't go in."
For residents with quadriplegia and multiple contractures, regular repositioning is critical to prevent pressure injuries, maintain circulation, and avoid respiratory complications. The inability to move independently means these residents rely entirely on staff responsiveness to meet basic care needs.
Sexual Abuse Incident in Memory Care Unit
Surveyors documented a substantiated sexual abuse incident that occurred on March 25, 2025, involving two residents in the facility's memory care unit. A Certified Nursing Assistant discovered a male resident (R17) in a female resident's (R43) room at approximately 3:00 AM.
According to the police report included in the inspection documentation, the CNA "walked into the room of [R43]. When she walked into the room, she saw another patient in [R43's] room, sitting on her bed. [The CNA] said the male patient had his hand in [R43's] underwear."
The police report further noted that R43 "is alert but cannot talk or move that much" and that R17 "is on multiple psych medications."
The CNA told surveyors: "I passed R43's room and saw R17 sitting on her bed. I asked him what he was doing, and he told me he was visiting a friend. He had his hand physically down her brief. As soon as R17 saw me, he withdrew his hand."
The male resident was transported to a hospital for psychiatric evaluation under Georgia's 1013 involuntary commitment process. The facility's investigation concluded the abuse was substantiated, and corrective measures included staff education, trauma assessments for both residents, updated care plans, and increased staffing in the memory care unit.
According to medical standards, residents with dementia who are unable to communicate or move require heightened supervision and monitoring. The inspection revealed the nurse on duty stated the last time she saw R17 was between midnight and 1:00 AM, indicating a gap of approximately two hours before the incident was discovered.
Pattern of Abuse Reporting and Investigation Failures
The inspection identified systemic problems with how Westminster Commons reported and investigated abuse allegations. Federal regulations require nursing facilities to report suspected abuse to state authorities within two hours of an allegation being made.
In the neglect incident involving R136, the nurse waited until morning to report the CNA's refusal to provide care, rather than immediately notifying the Director of Nursing or Administrator. The DON confirmed she "was not notified during the night by any staff" and the Administrator stated "Nobody called me."
A separate incident on October 3, 2024, revealed multiple reporting failures. At approximately 1:52 AM, a family member of one resident (R188) reported to police that a CNA had allegedly slapped the resident. The facility did not report this allegation to state authorities until 10:40 AM—approximately eight hours later.
Later that same day, R188 threw a full bottle of Gatorade at her roommate (R189) and directed racial slurs at her. This incident was not reported to state authorities until 8:34 PM, approximately ten hours after the facility became aware of it.
Additionally, during the early morning incident, witness statements documented that R188's family member had verbally abused R189, using profanity and racial language. This potential visitor-to-resident abuse was never reported or investigated by the facility.
The Administrator confirmed: "If [the family member] had come in and was verbally abusive to R189 there should have been a reportable incident to the State agency for that, which there was not."
The Regional Director of Clinical Operations stated that a thorough abuse investigation should include "speaking with all assigned staff at the time of the incident," interviewing "residents from the same room, and in the area to see if they heard anything or saw anything." She confirmed the investigations conducted were incomplete.
Conflicting Code Status Records Create Life-or-Death Confusion
Surveyors identified a critical documentation error affecting end-of-life care decisions for two residents. The facility's electronic medical record system displayed conflicting code status information that could result in inappropriate emergency response.
For one resident (R9), the EMR header displayed both "Full Code" and "Do Not Resuscitate" simultaneously. The resident's most recent Physician Orders for Life-Sustaining Treatment form indicated the family wanted full resuscitation, but an old DNR order had not been deleted from the system.
A Licensed Practical Nurse reviewing the record told surveyors "she was confused by the code status information that was displayed" and "it was not clear what action to take."
Another resident (R43) had a signed POLST form indicating Do Not Resuscitate status, but the physician order summary showed an active order for Full Code. The Social Services Director confirmed the orders "should have been changed in the system" weeks earlier but acknowledged the update never occurred.
Accurate code status documentation is essential for emergency medical response. When a resident experiences cardiac or respiratory arrest, staff must immediately know whether to initiate resuscitation efforts. Conflicting records can cause critical delays or result in unwanted interventions that violate the resident's expressed wishes.
Medication Administration and Care Planning Deficiencies
The inspection documented multiple instances of medications being administered significantly outside the required timeframe. Facility policy requires medications to be given within one hour of their scheduled time.
Review of one resident's medication records from January 2025 revealed 13 instances where medications were administered late, some by more than four hours. On January 17, 2025, four different medications scheduled for 9:00 AM were not administered until after 1:00 PM.
For another resident with a gastrostomy tube (G-tube), surveyors found that a Certified Medication Aide Tech had been administering medications by mouth rather than through the feeding tube as ordered by the physician. The resident had specifically expressed preference for medications through the G-tube because oral medications "tasted bitter."
The inspection also documented care planning failures. A resident on antipsychotic and antidepressant medications had no care plan addressing psychotropic medication monitoring. Another resident with a G-tube lacked any care plan for tube feeding care, nutrition, or medication administration through the device.
Additional Issues Identified
Beyond the major violations, surveyors documented numerous other deficiencies:
Call Light Accessibility: A quadriplegic resident's call light was repeatedly observed out of reach over multiple days. The resident reported having to call the nursing station using a cell phone and stylus held in his mouth because "half the time it's out of my reach."
Hearing Services: A resident with documented hearing loss who was recommended for a pocket talker device in September 2024 never received it. The Social Services Director discovered the invoice had not been paid.
Catheter Care: A resident's urinary catheter collection bag was observed resting on the floor on four separate occasions across two days, creating infection risk.
Bed Rail Safety: A resident was using side rails without proper assessment, physician orders, or informed consent documentation.
Staffing Information: The facility's posted nurse staffing information was seven days out of date when surveyors arrived.
Psychotropic Medication Monitoring: A resident on Trazodone for insomnia showed signs of drowsiness, including his head dropping into his plate at mealtime, but the facility had no orders for monitoring side effects. The Director of Nursing confirmed the resident "had been more drowsy than normal" and that the medication "should have been monitored for side effects."
Discharge Documentation: A resident's discharge summary was incomplete, missing required sections on psychosocial status and post-discharge care preparation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Commons from 2025-05-22 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.