Westbury Center: Medication Error Rate 7.69% - GA
The medication errors at Westbury Center of Conyers for Nursing and Healing pushed the facility's error rate to 7.69 percent during a federal inspection in August, well above the 5 percent threshold that triggers violations.
Inspectors observed 26 medication administration opportunities involving four residents. Two errors occurred with residents R89 and R77.
The first error involved atorvastatin calcium, a cholesterol-lowering medication prescribed as a 40-milligram daily tablet for R89, a resident with hyperkalemia, acute kidney failure, and encephalopathy. The facility had a December 2023 physician's order allowing medications to be crushed and mixed with food or liquid "unless contraindicated."
On August 27 at 8:12 a.m., Licensed Practical Nurse PP prepared, crushed, and administered the atorvastatin tablet to R89. When questioned immediately afterward, LPN PP confirmed she had crushed the medication. She also confirmed the medication should not be crushed.
The facility's registered pharmacist told inspectors that atorvastatin calcium tablets should not be crushed.
Nobody had checked.
The second error occurred 36 minutes later when Licensed Practical Nurse AA administered MiraLax powder to R77, a resident with paralysis and speech difficulties following a stroke. The physician's order from November 2022 specified 17 grams per scoop, one scoop daily for constipation.
LPN AA reviewed the physician's orders, then prepared and administered two scoops of the powder to R77. In an interview at 9 a.m., LPN AA confirmed the resident should have received one scoop. He administered two scoops "because the resident asked for a second scoop."
The nurse acknowledged he should have followed the doctor's order for one scoop.
Director of Nursing confirmed the next day that no exceptions existed for not following physician orders. Medication changes required contacting the provider and obtaining approval before administration.
The facility's medication administration policy, revised in April 2025, required staff to follow the "six rights" of medication administration: right resident, right drug, right dosage, right route, right time, and right documentation. The policy also mandated administering medications "as ordered in accordance with manufacturer specifications."
The Director of Nursing told inspectors that medications were to be crushed according to policy, and nurses should reference the list on each medication cart. But the system failed when LPN PP crushed a medication that pharmacists say should never be crushed.
R89's medical record showed no swallowing disorder according to a June quarterly assessment. The resident had been admitted to the facility and had standing orders allowing medication crushing when not contraindicated.
The atorvastatin error represented a fundamental breakdown in the medication safety system. The facility had policies requiring adherence to manufacturer specifications, a pharmacist available for consultation, and reference materials on medication carts. Yet a licensed nurse crushed a medication that should remain intact, potentially affecting the drug's effectiveness and safety profile.
The MiraLax error revealed a different problem: nurses making dosage decisions based on resident requests rather than physician orders. LPN AA doubled the prescribed dose without medical authorization, despite clear facility policies requiring provider approval for any medication changes.
Both errors occurred during routine morning medication administration rounds observed by federal inspectors. The mistakes happened within 36 minutes of each other, suggesting systemic rather than isolated problems with medication safety protocols.
The 7.69 percent error rate exceeded federal standards designed to protect nursing home residents from medication-related harm. Federal regulations limit error rates to less than 5 percent to reduce risks of adverse drug effects, treatment failures, and other complications.
R89 faced potential consequences from receiving crushed atorvastatin, including altered drug absorption and effectiveness. R77 received twice the prescribed constipation medication dose, risking side effects from the excess amount.
The inspection found that both residents remained at risk of adverse effects or lack of desired therapeutic outcomes from their medications due to the administration errors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westbury Center of Conyers For Nursing and Healing from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WESTBURY CENTER OF CONYERS FOR NURSING AND HEALING in CONYERS, GA was cited for violations during a health inspection on August 28, 2025.
Inspectors observed 26 medication administration opportunities involving four residents.
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.