The facility's investigation into the September incident was so inadequate that administrators couldn't determine what actually happened, despite having a witness in the room.
Resident #215 rang the call bell for bathroom assistance on September 25 during the 3 PM to 11 PM shift. After more than two hours of waiting, Geriatric Nursing Assistant #17 finally entered the room. The resident became upset about the delay, leading to an argument between the two.
During that argument, the nursing assistant called the resident a "blind bitch," the resident told federal inspectors on October 8. The resident's roommate witnessed the entire exchange.
The resident chose not to respond to the slur and reported the incident to Social Service Director #2 the following day at 1:30 PM.
What followed was an investigation that missed basic steps and failed to interview key witnesses, according to inspection records obtained during a complaint investigation on October 9.
The administrator launched an abuse investigation but conducted only superficial questioning of staff members. Four employees who worked on Unit One during the shift were asked a single question: "Have you witnessed any staff member verbally abuse any resident?" All four answered no.
No follow-up questions were asked. No details were sought about the specific incident involving Resident #215.
The investigation grew more problematic when administrators questioned residents on the unit. Using an abuse questionnaire on September 26, Social Service Director #2 asked residents: "Have you seen any resident here being abuse?"
All residents answered no except Resident #218, who said yes.
The questionnaire form indicated that any "yes" response required collecting additional information and reporting immediately. But no follow-up documentation exists showing anyone spoke with Resident #218 again about what they witnessed.
Most critically, investigators never interviewed the roommate who was present during the alleged verbal abuse.
When federal inspectors interviewed the administrator and Director of Nursing on October 8, they asked how she reached an "inconclusive" finding without conducting proper interviews.
The administrator acknowledged that while interviews were conducted using questionnaires, they were not documented. She explained that two residents reported verbal abuse and two staff members denied it, leaving her unable to verify the allegations.
When inspectors asked for evidence supporting the staff members' statements that the nursing assistant did not curse at Resident #215, the administrator admitted she had no documents to support those claims.
The inspection revealed a pattern of inadequate investigation practices. Despite having a witness in the room during the alleged incident, administrators failed to interview that person. Despite having a resident who reported witnessing abuse, no one followed up on their statement.
The facility's investigation file contained documentation that staff and resident interviews were conducted, but the actual interview records were missing except for the questioning of the accused nursing assistant.
Resident #215 confirmed to inspectors that their roommate was present during the verbal altercation with the nursing assistant. That roommate could have provided crucial testimony about whether the slur was actually used.
Instead, the administrator relied on generic questionnaires that asked broad questions about abuse rather than specific inquiries about the September 25 incident.
The federal inspection was triggered by a complaint, though records don't specify whether the complainant was the resident, family members, or facility staff.
The case illustrates how nursing home investigations can fail residents when administrators don't follow through on basic investigative steps. A witness was available but never questioned. A resident reported seeing abuse but was never interviewed further.
For Resident #215, who is legally blind and dependent on staff for basic needs like bathroom assistance, the two-hour wait represented a failure of care even before the alleged verbal abuse occurred.
The resident's vulnerability was compounded by what they described as a nursing assistant's cruel response to their frustration about the delayed assistance.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But the deficiency points to broader problems with how the facility handles abuse allegations and protects vulnerable residents.
The inspection found that Westgate Hills failed to ensure all alleged violations involving mistreatment were thoroughly investigated, as required by federal regulations.
When residents report abuse, facilities must conduct comprehensive investigations that include interviewing witnesses and documenting their findings. The September investigation fell short of those standards.
The administrator's admission that she lacked documentation to support staff denials of the abuse allegation highlighted the investigation's fundamental flaws.
Resident #215 remains at the facility, still dependent on nursing assistants for basic care needs including bathroom assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westgate Hills Rehab & Healthcare Ctr from 2025-10-09 including all violations, facility responses, and corrective action plans.
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