F-F600 Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 115674
F-F600 Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 115674
F-F605
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558 Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20402 potential for actual harm Based on observations, record review, facility policy review, and resident and staff interviews, the facility Residents Affected - Few failed to ensure residents' call light was within reach for one of one resident (Resident (R)136) reviewed for accommodation of needs. This failure placed the resident at risk of functionality not being maintained due to severe physical limitations, dignity, and well-being in accordance with his own needs and preferences, the resident could potentially not be able to call for assistance when needed.
Findings include:
Review of the facility's policy titled, Accommodation of Needs, revised March 2021, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The policy further indicated, The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.
Review of the facility's policy titled, Call Light, Answering, dated April 2022 indicated, The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .
Review of Resident R136's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed Resident R136 was admitted to the facility on [DATE REDACTED] with diagnoses that included functional quadriplegia, displaced spiral fracture of shaft of humerus, right arm, posterior subluxation [incomplete or partial dislocation of a joint or organ] of right hip, contracture of muscle unspecified upper arm, contracture of muscle left upper arm, contracture of muscle right lower leg, contracture of muscle left lower leg, and complete lesion at C5 [cervical spinal vertebrae] level of cervical spinal cord.
Review of Resident R136's Nursing Initial 48-hour Care Plan, dated 10/31/24 and located under the Assessment tab of the EMR, indicated, Specialty Interventions Related to Resident's Health Condition. Intervention: Resident call light and bedside table on dominant side.
Review of Resident R136's Care Plan, dated 11/01/24 and located under the Care Plan tab of the EMR, indicated [name of Resident R136] is (high) risk for falls r/t [related to] Paralysis, bilateral [affecting both sides] lower/upper extremity contractures. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
Review of the Resident R136's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident R136 had impairments on both sides of the upper and lower extremities, and the resident was completely dependent on staff for Activities of Daily Living (ADLs).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558 Review of Resident R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15 which indicated the Level of Harm - Minimal harm or resident was cognitively intact. The MDS further indicated that Resident R136 had impairments on both sides of the potential for actual harm upper and lower extremities and was completely dependent on staff for ADLs.
Residents Affected - Few During an observation and interview on 05/19/25 at 10:30 AM, Resident R136 was observed lying in bed on his right side. At this time, the flat round touch pad call light and cord was observed to be hanging over the mobility bar located behind the resident on the left side of the head of the bed and almost touching the floor. Resident R136's call light touch pad device was completely behind Resident R136 where he could not reach it. Resident R136 was observed to have a red stylus pen in his mouth and only able to use his stylus to touch his cell phone and move his head up and down. Resident R136 stated, I need help with everything. I cannot move my body. My legs and hands are contracted. I can only move my head a little. Resident R136 then stated, When I need help, I have to get on my phone and call the nurses station by dialing the number with my pen that I hold in my mouth. When Resident R136 was asked if he could use his touch pad call light to call for assistance, he stated, Yes, but only if they put the call light close to me where I can hit it with my chin. Yes, I would be able to use it, but half the time it's out of my reach.
During an observation on 05/19/25 at 12:30 PM, Resident R136 was lying in bed on his right side. The flat round touch pad call light and cord was again to be observed to be hanging over the mobility bar located behind the resident on the left side of the head of the bed and out of reach.
During an observation on 05/19/25 at 3:00 PM, Resident R136 was lying in bed on his left side. The flat round touch pad call light and cord was still observed to be located hanging over the mobility bar located on the left side of the head of the bed and almost touching the floor. At this time, it was not positioned where the resident could use it.
During an observation on 05/20/25 at 12:11 PM, Resident R136 was lying in bed on the right side. At this time, he was talking on the cell phone that was observed to be mounted to the mobility bar on the right side of the head of
the bed. At this time, the flat round touch pad call light and cord were observed to not be within reach and hanging over the mobility bar located behind the resident on the left side of the bed and almost touching the floor.
During an observation on 05/20/25 at 1:41 PM, Resident R136 was lying in bed on the right side with his eyes closed. At this time, the flat round touch pad call light and cord were observed to not be within reach and hanging over the mobility bar and almost touching the floor as was before.
During an interview on 05/20/25 at 1:45 PM, Licensed Practical Nurse (LPN) 4 was asked if Resident R136 would be able to use the touch pad call light to call for assistance. LPN4 stated, Yes, he would be able to use it. He can move his head and chin to push it if he needed to. He is alert and oriented x4.
During an interview on 05/20/25 at 1:47 PM, Registered Nurse (RN) 3 was asked if Resident R136 would be able to use the touch pad call light to call for assistance. RN3 stated, Yes, he has a 'Pancake' touch pad 'that's what
we call it,' that he can use. He can also use his stylus and push the call light. Yes, he can definitely use it.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558 During an interview on 05/20/25 at 1:50 PM, LPN1 was asked if Resident R136 would be able to use the touch pad call light to call for assistance. LPN1 stated, Yes, he is total care [completely dependent on staff]. He must Level of Harm - Minimal harm or have everything done for him. He can use the touch pad call light if it is close to him. He is able to move his potential for actual harm head to touch it.
Residents Affected - Few During an observation on 05/20/25 at 2:55 PM, Resident R136 was lying in bed on his back. At this time, the flat touch pad call light and cord was observed to not be within reach of the resident and was observed to be hanging over the mobility bar on the left side and almost touching the floor.
During an observation on 05/20/25 at 3:05 PM, Resident R136 was observed lying in bed on his back. At this time, the flat touch pad call light was now observed to be next to the resident's chin to where he could push it if needed.
During an interview and observation on 05/21/25 at 10:12 AM, Certified Medication Aide Tech (CMAT) 2 was asked if Resident R136 could use the flat touch pad call light to call for assistance if needed. CMAT2 stated, Yes [name of Resident R136] can use his call light but only if you put it by his head or shoulder and position it to where he can use it. He can use his head to push it, but it needs to be positioned close by. At this time during an
observation with CMAT2, Resident R136 was lying on the left side of the bed. The call light was observed to be hanging over the mobility bar behind the resident and almost touching the floor. It was observed to be out of reach. At this time, CMAT2 stated, It shouldn't be like this and confirmed it was not within reach of Resident R136. CMAT2 proceeded to pick it up from the mobility bar and place it near the resident's head to where he could reach it.
During an observation and interview on 05/22/25 at 5:30 AM with LPN7, Resident R136 was lying on his back in bed with his eyes closed. The flat touch pad call light was observed to be located near Resident R136's chin to where he could tap it if needed. LPN7 was asked if Resident R136 could use the flat touch pad call light to call for assistance,
the LPN stated, Yes, he can use it. There have been times when I've come in and the call light is on the floor. He can also use his stylus to use his cell phone to call us if he needs anything. As his nurse, I would expect the call light [to] be within his reach.
During an interview on 05/22/25 at 10:30 AM, regarding the use of call light being accessible for Resident R136, and what the expectation would be, the Director of Nursing (DON) stated, The call light should be within reach at all times.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39540
Residents Affected - Few Based on record review, staff interviews, and review of the facility's policy, the facility failed to ensure their primary system for identifying a resident's code status accurately reflected the resident's end of life wishes for two of 46 sampled residents (Resident (R) 9 and Resident R43) reviewed for code status. This failure placed the residents at risk for their wishes not to be honored, risk of there being a delay in treatment, and death.
Findings include:
1. Review of Resident R9's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE REDACTED] and a readmitted [DATE REDACTED].
Review of Resident R9's EMR header information revealed the resident's code status was identified as Full Code and Do Not Resuscitate (DNR).
Review of Resident R9's Physician's Orders for Life Sustaining Treatment (POLST) form dated [DATE REDACTED] and located in
the resident's EMR under the Misc tab revealed Do Not Resuscitate [DNR] was selected. The POLST form was signed by the resident's representative and the resident's physician.
Review of Resident R9's Progress Note, dated [DATE REDACTED] and located in the resident's EMR under the Progress Notes tab revealed the Social Services Director (SSD) documented, A care plan meeting was held with the resident and his daughter today. Resident/family desire a full code status and wishes will be honored at this time. The resident will remain in this facility for LTC [long term care]. No questions or concerns.
Review of Resident R9's POLST form dated [DATE REDACTED] and located in the resident's EMR under the Misc tab revealed Attempt Resuscitation (CPR [Cardiopulmonary Resuscitation]) was selected which indicated the resident's code status was Full Code. The POLST form was signed by the resident's representative and the resident's physician.
Review of Resident R9's Physician Order located in the resident's EMR under the Orders tab revealed an order dated [DATE REDACTED] of Code Status: Do Not Resuscitate and an order dated [DATE REDACTED] of Code Status: Full Code.
During a record review and interview on [DATE REDACTED] at 11:33 AM, Licensed Practical Nurse (LPN) 2 reviewed the header in Resident R9's EMR for code status. LPN2 stated she was confused by the code status information that was displayed as the EMR header indicated the resident was both a Full Code and a DNR and it was not clear what action to take.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 During an interview on [DATE REDACTED] at 3:51 PM, the SSD stated the process for when a resident and/or representative requested a code status change, an updated POLST form was completed (signed by Level of Harm - Minimal harm or resident/representative and a physician), then uploaded to the resident's EMR under the Misc tab, and then potential for actual harm an email was sent to nursing to update the resident's physician's order and the resident's care plan in the EMR. The SSD also stated the change in code status was also communicated in the daily morning meeting Residents Affected - Few for the facility staff.
During an interview on [DATE REDACTED] at 9:21 AM, the LPN3 confirmed the process for updating a resident's code status was once the SSD informed nursing of the need to update the code status in the EMR, an order would be added to the physician's orders, and if there was a previous order, that order would be discontinued. LPN3 also stated during the process of updating the code status for Resident R9, she was interrupted and failed to delete the old code status order resulting in the resident's EMR indicating two different code status options. LPN3 further stated this was where the nurses referred to when they needed to know what a resident's code status was. LPN3 stated Resident R9's EMR which reflected two different code statuses and two different physician orders would create confusion about what to do for the code status of Resident R9.
During an interview on [DATE REDACTED] at 12:46 PM, the Director of Nursing (DON) confirmed there was usually an audit done for orders updated in the daily morning meeting to ensure two people were reviewing the orders.
This was not done for Resident R9 when the new POLST order was updated, and it should have been confirmed by a second nurse.
2. 2. Review of Resident R43's Admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE REDACTED].
Review of Resident R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE REDACTED] and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score was not assessed and the staff documented Resident R43 as having severely impaired cognition.
Review ofR43's Care Plan, located under the Care Plan tab of the EMR and initiated on [DATE REDACTED], revealed
the Resident/ family desires a DNR [Do Not Resuscitate] status.
Review of Resident R43's physician Order Summary Report located under the Orders tab of the EMR revealed an active order for code status: Full Code, order date [DATE REDACTED].
Review of Resident R43's Physician Orders for Life-Sustaining Treatment (POLST) located under the Misc tab of the EMR, dated [DATE REDACTED] and signed by the physician on [DATE REDACTED], revealed Allow Natural Death (AND)- Do Not Attempt Resuscitation.
During an interview on [DATE REDACTED] at 7:43 AM, the Licensed Practical Nurse (LPN) 1 stated they would look in
the EMR for the correct code status. She stated it would have been a discrepancy in the medical record as described above, and the EMR physician order would trump it.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 During an interview on [DATE REDACTED] at 8:04 AM, the Social Services Director (SSD) stated when a resident was admitted , she gave them the POLST to sign and asked if they had a Power of Attornaey (POA). She stated Level of Harm - Minimal harm or that the form then got sent to the business office and uploaded. She stated she audited for changes and potential for actual harm would send an email to the Unit Manager and Director of Nursing (DON); along with mentioning it in the morning clinical meeting. The SSD confirmed Resident R43's code status was a DNR after looking at the EMR. She Residents Affected - Few verified the orders had not been changed to reflect it. She stated it should have been changed in the system
on [DATE REDACTED]. She stated she had sent an email on [DATE REDACTED] to the Unit Manager and the DON, along with talking about it in the morning meeting.
During an interview on [DATE REDACTED] at 11:30 AM, the DON stated there was a miscommunication with the SSD and it should have been changed immediately.
During an interview on [DATE REDACTED] at 12:15 PM, the DON stated she had a lot going on that day and missed it.
Review of the facility's policy titled Advanced Directives, revised ,d+[DATE REDACTED], revealed Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record
in a section of the record that is retrievable by any staff.a
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20402
Residents Affected - Some Based on observation, record review, facility policy review, and resident, resident family, and staff interviews,
the facility failed to ensure four of eight residents (Residents (R) 17, 43, 136, and 188) reviewed for abuse out of 46 sampled residents were free from abuse. This had the potential and/or physical harm to the residents.
Findings include:
Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated, Residents have the right to be free from abuse, neglect . Protect residents from abuse, neglect .by anyone including but not necessarily limited to: a. facility staff; b. other residents .Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; neglect of residents .identify and investigate all possible incidents of abuse, neglect .protect residents from any further harm during investigations.
Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated 08/22/22 indicated, It is the policy of this center that each resident has the right to be free from mistreatment of any kind .Each resident will be treated with respect and dignity at all times. The center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect . Definitions .Neglect means the failure of the center .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .
1.Review of a Facility Incident Report dated 03/06/25 indicated Type of Incident-Neglect. Details of Incident- [name of Resident R136] is alleging that Certified Nursing Assistant (CNA) [48] neglected him by not turning him timely.
Review of the Facility Follow Up Investigation dated 03/13/25 indicated, [name of Resident R136] alleged that [name of CNA 48] neglected him by not turning him timely. The investigation indicated [name of Resident R136] said he called and requested assistance at 2:03 AM on March 6, 2025. He said the CNA did not come to his room until 6:30 AM. When [name of CNA 48] was interviewed, she said she did not go in until 6:30 AM as she felt
the resident was rude. The facility concluded, It was determined that the accusation of neglect was Substantiated.
Review of Resident R136's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed Resident R136 was admitted to the facility on [DATE REDACTED].
Review of Resident R136's Care Plan, dated 11/01/24 and located under the Care Plan tab of the EMR, indicated [name of Resident R136] is (high) risk for falls r/t [related to] Paralysis, bilateral [affecting both sides] lower/upper extremity contractures. Interventions indicated, The resident needs prompt response to all requests for assistance.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 Review of Resident R136's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to Level of Harm - Minimal harm or have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was potential for actual harm cognitively intact. The MDS also indicated Resident R136 had impairments on both sides of the upper and lower extremities, and the resident was completely dependent on staff for Activities of Daily Living (ADLs). Residents Affected - Some
Review of Resident R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS further indicated that Resident R136 had impairments on both sides of the upper and lower extremities and was completely dependent on staff for ADLs.
During an observation and interview on 05/19/25 at 10:30 AM, Resident R136 was lying in bed. Resident R136 was observed to have a red stylus pen in his mouth and only able to use his stylus pen to touch his cell phone which was mounted to the mobility bar. He was also observed to only be able to move his head up and down. During an interview, Resident R136 stated, From what I remember this was on a Wednesday .I called the nurse who told me someone was coming. I called around 2:00 AM or so. The CNA [identified as CNA48] 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 [referring to CNA48] told me that I would have to wait until the next shift. She told me she was busy and would not be able to help me. Then around 6:00 AM or 6:30 AM, or so she came to change my roommate then told me I can do you, but this will be the first and last time I do this. Resident R136 stated, The nurse [identified as Registered Nurse (RN) 2] came in and told me, 'I asked [name of CNA48] to come in and turn you.' The resident stated that he was eventually turned, but it was around 6 or 6:30 AM. When this incident occurred, Resident R136 stated This was unacceptable, and I felt like it was neglect.
Review of a written statement from RN2 dated 03/10/25 and provided by the facility indicated, I had asked
the CNA [referring to CNA48] who was the assigned CNA to be working with [name of Resident R136] to go and turn him at 2:00 AM. She refused. I let the CNA know that refusing to do a patient that is assigned to you on a shift is a problem. She agreed with me but still refused. I told her I was going to report her to the DON [Director of Nursing], and she said, 'you can go right ahead.' .The CNA [referring to CNA 48] went into [name of Resident R136] room around 5:00 AM or so to turn him. He was very upset about the whole situation.
Review of a phone interview that was conducted with CNA48 on 03/03/25 revealed, [name of CNA48] stated that everything started on Monday March 3, 2025. [name of CNA48] said Resident R136 wanted her to get him ready at 3am for a 7am Dr. appointment. She [CNA 48] told him that it was too early, and she would get him ready at 6:00 AM. He refused and she told him that the CNA coming in for the next shift would get him ready. He [Resident R136] got upset. When asked about the incident that occurred Wednesday night [referring to March 6, 2025], she [CNA48] admitted that she did not go into [name of Resident R136's] room to provide care for him until 6:30 AM.
During an interview on 05/20/25 at 11:11 AM, regarding the incident that occurred on 03/06/25 involving Resident R136, the Administrator stated, I was contacted by the Social Worker on March 6, 2025, that he [referring to Resident R136] had concerns and since he used the word 'neglect' we reported it as an allegation of neglect. He then stated, The girl [referring to CNA48] confessed that she didn't go back into his room until 6:30 AM, so we substantiated it for neglect.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 During an interview on 05/21/25 at 7:13 AM, regarding the incident that occurred with Resident R136 and CNA48 on 03/06/25, RN2 stated that she was the nurse working the night of March 6, 2025. RN2 stated, He [referring to Level of Harm - Minimal harm or Resident R136] called and said that he needed to be turned around 2:00 AM or 2:30 AM. I told him I would send potential for actual harm someone in his room. I told [name of CNA48] since you have him on your assignments, and since you are his assigned CNA, you need to go and turn him. She [referring to CNA48] started arguing that nobody told Residents Affected - Some her she had him. She refused to go into his room and was saying she wasn't assigned to him. I told her since
she was on the clock and was assigned to him that she needed to go into his room and turn him. She again said that she was not going to. I told her I was going to let the Director of Nursing know that you are refusing to turn him. RN2 stated Towards the end of the morning around 5:00 AM or 5:30 AM or so I went in the room with [name of CNA48] and apologized to him about the confusion as to who was assigned to him. He was very upset. At that time, we ended up turning him. He was not wet. He just needed to be turned. RN2 stated that she waited until morning until the DON came into work to report the incident. During a second interview
on 05/21/25 at 2:53 PM regarding the incident that occurred with Resident R136 and CNA48 on 03/06/25, when RN2 was asked why she did not assist Resident R136 when he was requesting to be turned around 2:00 AM or 2:30 AM, RN2 stated, I was busy with my work. I asked [name of CNA48] and she told me she wasn't going to do it. I had my own work to do. I want to say we went into his room around 5:00 AM or 5:30 AM or so to turn him.
An unsuccessful attempt to contact CNA48 via phone was made on 05/21/25 at 9:30 AM.
During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, the DON stated she was not notified during the night by any staff which included RN2 about any incident regarding Resident R136 until she came into work around 7:30 AM the next morning. The DON stated, I agree it would be neglect on part of the nurse and the CNA. She [regarding RN2] should have called me or the Administrator immediately. We did not focus on why the nurse did not go into the room to turn him. We were more focused
on why the CNA didn't go in. She [referring to RN2] as the nurse could have gone in his room to turn him.
During an interview on 05/21/25 at 1:00 PM, the Administrator stated he was not notified by RN2 or CNA48 of this incident anytime during the night. He stated, Nobody called me. The Administrator stated, I see where
it was neglect on part of the nurse as well when this happened. She should have called me, and she also could have gone into his [referring to Resident R136] room and turned him.
2. Review of Resident R189's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED]. The resident discharged on [DATE REDACTED].
Review of Resident R189's discharge Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with
an Assessment Reference Date (ARD) of 10/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. Resident R189 had no delirium, no mood, and no behaviors.
Review of Resident R188's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED].
Review of Resident R188's quarterly MDS located in the MDS tab in the EMR, with an ARD of 10/12/24, revealed a BIMS score of eight out of 15, which indicated moderate cognitive impairment.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 Review of Resident R188's discharge MDS assessment located in the MDS tab in the EMR, with an ARD of 12/06/24, documented the resident had verbal behavioral symptoms directed toward others for one to three days Level of Harm - Minimal harm or during the assessment period. potential for actual harm
Review of Resident R188's Care Plan, initiated 02/19/24, documented the resident displayed verbally/physically Residents Affected - Some abusive behaviors and racial comments such as hitting and spitting at staff. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document, and to assess the resident's understanding of the situation. The care plan was last revised on 08/21/24, prior to the 10/03/24 incident.
Review of Resident R188's Care Plan, located in the EMR under the Care Plan tab and initiated 04/18/24, revealed Resident R188 was verbally abusive. Interventions included to provide one-to-one supervision as needed.
Review of the Facility Incident Report form, dated 10/03/24, provided by the facility revealed that on 10/03/24 at approximately 10:32 AM, Resident R188 was documented to have thrown a full bottle of Gatorade at Resident R189 and call her names. The bottle did not make contact with Resident R188.a skin assessment was conducted .no areas of redness or bruising were present .(Resident R188) was immediately removed, and her room was changed .The police, physician, responsible, and Ombudsman were notified.
Witness statement from Resident R189, dated 10/03/24, stated, .(Resident R188) was yelling and calling me out .throw (sic) a full drink at me and it hit the floor.
Review of Resident R188's Progress Note, located under the Progress Note tab in the EMR and dated 10/03/24 at 10:32 AM, indicated that .was made aware by the Activity Coordinator that the resident threw her unopened Gatorade bottle at her roommate (Resident R189) .The resident was cursing at the roommate and told her to Get out . Went into the room along with the Director of Nursing (DON) and spoke with the resident .Made her aware that she cannot throw items at her roommate, other residents or staff.
Review of the Facility Incident Report investigation revealed that staff members interviewed all stated that
they heard (Resident R188) call (Resident R189) a Black B---- and then they heard the sound of the bottle hitting the floor . When the officer arrived at the facility, the officer interviewed both residents .The officer issued a citation to (Resident R188) for disorderly conduct.
During an interview on 05/22/25 at 6:58 AM, the Administrator stated that during his investigation of the 10/03/24 resident to-resident abuse between Resident R188 and Resident R189 he learned that Resident R188 had thrown a bottle of Gatorade at Resident R189, but it did not hit her. He stated that he moved Resident R188 to a different room. The Administrator stated that this was why the police officer came back to the facility and issued Resident R188 a citation for a warrant.
3. Review of Resident R17's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED].
Review of Resident R17's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) was not assessed and the staff documented Resident R17 as having severely impaired cognition.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 Review of Resident R17's Progress Note dated 03/25/25 and located under the Progress Notes tab of the EMR revealed Resident was observed in female room with hands in her diaper. Resident was removed from the Level of Harm - Minimal harm or room immediately and put one on one monitoring, female resident was assessed and unharmed at this time, potential for actual harm resident's family notified of incident, DON [Director of Nursing] and administrator notified at this time. Resident was transferred to [name] hospital for a psych [psychiatric] evaluation. Residents Affected - Some 3. Review of Resident R43's Admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE REDACTED].
Review of Resident R43's quarterly MDS with an ARD of 03/28/25 and located under the MDS tab of the EMR revealed a BIMS score was not assessed and the staff documented Resident R43 as having severely impaired cognition.
Review of Resident R43's Progress Note dated 03/25/25 and located under the Progress Notes tab of the EMR revealed Resident was assessed and remains unharmed, no bruising or redness noted to vaginal area, no injuries noted. Resident's family notified of incident.
During an interview on 05/19/25 at 12:59 PM, Family Member (FM) 1 stated there was an incident that he was aware of with Resident R43 and another resident. He stated she was fine, and nothing happened and that they (the staff) had stopped it before anything occurred.
Review of the facility's investigation, pr
ovided by the facility and dated 03/31/25, revealed The nurse on duty stated that the last time she saw [Resident R17] was between 12:00 AM and 1:00 AM. She said he was lying in his bed .it was determined after a thorough investigation that it was substantiated .We will implement the following measures: 1. Staff education on identifying and reporting changes in behavior. 2. Staff education on handling changing residents. 3. Both residents received a trauma assessment. 4. Both residents' care plans were updated. 5. Resident will both be seen by psych services. 6. Medical Director/ NP [Nurse Practitioner] is reviewing and modifying [Resident R17's] medication.
Review of the police report provided by the facility, dated as first reported 03/25/25, revealed Once on the scene, I spoke to the call [Certified Nursing Assistant (CNA) 16] who explained that while she was working at
the nursing home .she walked into the room of [Resident R43]. When she walked into the room, she saw another patient in [Resident R43's] room, sitting on her bed. [CNA16] said the male patient; [Resident R17] had his hand in [Resident R43's] underwear .I was told that [Resident R43] is alert but cannot talk or move that much. As for [Resident R17], he is on multiple psych medications .one on one with [Resident R17] until was transported.
During an interview on 05/20/25 at 10:40 AM, Registered Nurse (RN) 1 stated before the incident Resident R17 had been staring at women, appeared drooling, and then he would start to laugh. She stated he was very aggressive before he was sent out for two weeks. She stated he was very calm now. She stated they had two CNAs on the floor since the incident and a lot of in-services.
During an interview on 05/20/25 at 12:59 PM, the DON stated Resident R17 had behaviors which was why he was in
the memory care unit. She stated she was not aware of any sexual behaviors before the incident.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 During an interview on 05/21/25 at 10:29 AM, the Administrator stated Resident R17 was fine before the incident, and
he was not aware of any behavior prior to. He stated he got a call from a nurse, and he drove to the facility. Level of Harm - Minimal harm or He stated the police were already at the facility and that Resident R17 was in the common area. He stated Resident R17 left the potential for actual harm facility using 1013 transport (legal document used to authorize the involuntary transportation and evaluation of an individual experiencing severe mental health crisis). He stated no other facility was willing to take him. Residents Affected - Some He stated he was told [Resident R17] tried to put his hand inside. He stated he had to complete his report before he received the police report. He stated to his understanding Resident R17 touched Resident R43's naval area and not inside her brief. He stated for safety; they increased staffing in the memory care unit.
During an interview on 05/21/25 at 12:17 PM, CNA16 stated at around 3:00 AM, she had gone upstairs to
the supply closet. She stated when she came back down, she passed Resident R43's room and saw Resident R17 sitting on her bed. She stated she asked him what he was doing, and he told her he was visiting a friend. She stated Resident R17 had his hand physically down her brief. She stated she felt like he had just done that, and it had not been long. She stated as soon as Resident R17 saw her, he withdrew his hand. She stated she had never seen that behavior from him. She stated he was sent out by 7:00 AM.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0605 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33865
Residents Affected - Few Based on record review, staff interviews, and facility policy review, the facility failed to ensure monitoring of psychotropic medication side effects was conducted for one of six residents (Resident (R) 336) reviewed for unnecessary medications of 46 sample residents. This failure had the potential to result in an excess of medication provided to the residents resulting in oversedation.
Findings include:
Review of the facility's undated policy titled, Alternatives to Antipsychotics for Mood Disorders and Behaviors
in LTC [Long Term Care], revealed Trazodone was indicated for depression. Trazodone has been used in mood disorders associated with poor/diminished sleep .Monitor for efficacy .Monitor for increased falls risk and cumulative anticholinergic side effects.
Review of Resident R336's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident R336 had diagnoses which included dementia. The resident expired on [DATE REDACTED].
Review of Resident R336's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) was not assessed and the resident was documented as having severely impaired cognition.
Review of Resident R336's Care Plan located under the Care Plan tab of the EMR revealed the resident used antidepressant medication, resolved [DATE REDACTED]. Interventions included reporting to nurses, signs and symptoms which included fatigue, change in normal behavior, and insomnia.
Review of Resident R336's Care Plan, located under the Care Plan tab of the EMR revealed the resident used psychotropic medications, resolved [DATE REDACTED]. Interventions included monitoring, recording, and report to MD [Medical Doctor] prn [as needed] side effects and adverse reactions which included fatigue and insomnia.
Review of Resident R336's physician Order Summary Report located under the Orders tab of the EMR revealed an order, dated [DATE REDACTED], of Trazodone HCL [hydrochloride] oral tablet 50 MG (milligrams). Give one tablet by mouth at bedtime for insomnia. The Trazodone was discontinued on [DATE REDACTED]. There were no orders related to
the monitoring of side effects for Trazodone use.
Review of the facility's investigation dated [DATE REDACTED]and provided by the facility revealed the resident was observed drowsy at the dining table. Head dropped to the plate. Staff quickly raised Resident R336's head from the plate.
Review of Resident R336's Progress Note dated [DATE REDACTED] and located under the Progress Notes tab of the EMR revealed Observed drowsy but able to awaken without difficulty. NP [Nurse Practitioner] made aware with orders for UA C&S [urinary analysis culture and sensitivity] and CMP [comprehensive metabolic panel] on Monday. Daughter made aware but preferred for resident to be sent to the emergency room for evaluation.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0605 During an interview on [DATE REDACTED] at 8:21 AM, the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) both confirmed there should have been monitoring for the Trazodone. The DON Level of Harm - Minimal harm or stated Resident R336 had been more drowsy than normal. She also stated he had been drowsy on and off. They potential for actual harm stated this medication should have been monitored for side effects.
Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20402
Residents Affected - Few Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure all allegations of abuse and neglect were reported immediately but not later than two hours after
the allegation for two of eight residents reviewed for abuse and/or neglect (Resident (R) 136 and Resident R188) out of 46 sampled residents. This failure placed all residents of the facility at risk for further abuse and/or neglect.
Findings include:
Review of the facility's policy titled, Abuse Prevention Policy, last revised 03/01/18, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .The resident has the right to be free from mistreatment, neglect .Reports of allegations or suspected abuse, neglect or exploitation .will be reported immediately .When abuse, neglect or exploitation is suspected the Licensed Nurse should: .Notify the Director of Nursing and Administrator .When suspicion or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made .
1.Review of a Facility Incident Report, dated 03/06/25 revealed Type of Incident-Neglect .Details of Incident- [name of Resident R136] is alleging that Certified Nursing Assistant (CNA) 48 neglected him by not turning him timely.
Review of Resident R136's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed Resident R136 was admitted to the facility on [DATE REDACTED].
Review of the Resident R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.
Review of Resident R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
During an observation and interview on 05/19/25 at 10:30 AM, Resident R136 lying in bed. When Resident R136 was asked about the incident regarding CNA48. he stated, This was unacceptable, and I felt like it was neglect. Review of a written statement from RN2 dated 03/10/25 and provided by the facility revealed I had asked the CNA [referring to CNA 48] who was the assigned CNA to be working with [name of Resident R136] to go and turn him at 2:00 AM. She refused. I let the CNA know that refusing to do a patient that is assigned to you on a shift is a problem. She agreed with me but still refused. I told her I was going to report her to the DON [Director of Nursing] .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609 During an interview on 05/21/25 at 7:13 AM, regarding the incident that occurred with Resident R136 and CNA 48 on 03/06/25, RN2 stated that she was the nurse working that nightRN2 stated, He [referring to Resident R136] called and Level of Harm - Minimal harm or said that he needed to be turned around 2:00 AM or 2:30 AM. I told him I would send someone to his room. I potential for actual harm told [name of CNA48] since you have him on your assignments, and since you are his assigned CNA, you need to go and turn him. CNA48 refused to go into Resident R136's room. I told her I was going to let the Director of Residents Affected - Few Nursing [DON] know that you are refusing to turn him. RN2 stated that she waited until morning until the DON came into work to report the incident.
During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, the DON stated that she was not notified during the night by any staff which included RN2 about any incident regarding Resident R136. The DON also stated when she came into work around 7:30 AM (over five hours later from when Resident R136 requested assistance) that morning, RN2 reported the incident to her. he DON further stated, . [RN2] should have called me or the Administrator immediately but that didn't happen. The DON then stated, I agree it was also a delay in reporting to me or the Administrator. The nurse [referring to RN2] waited many hours to report the CNA [referring to CNA48] not wanting to turn a resident. She waited to report anything until I came in to work at 7:30 AM.
During an interview on 05/21/25 at 1:00 PM, the Administrator stated that he was not immediately notified by RN2 or CNA48 of the neglect incident during night shift. The Administrator also stated, Nobody called me.
The Administrator stated, I was notified by the Social Worker that following morning that [name of Resident R136] had
a complaint about not being turned the previous night. The Administrator stated it was his expectation he would have been immediately notified of the neglect.
2. Review of Resident R188's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED]. The resident was discharged on [DATE REDACTED].
Review of the Facility Incident Report form, dated 10/03/24, revealed that the resident representative for Resident R188 reported to the police that Certified Nursing Assistant (CNA)50 allegedly slapped Resident R188 twice to the right side of her face. The CNA was suspended pending the outcome of the allegation.
Review of the Police Incident Report revealed that on 10/03/24 at approximately 1:52 AM, there was a reported allegation of staff-to-resident abuse between Resident R188 and CNA50. The family member of Resident R188 (FM) 2 was also documented in the facility at this time.
Review of the Administrator email to the State agency revealed the incident was State reported as an allegation of potential abuse on 10/03/24 at 10:40 AM, about 8 hours later, which was a delay in reporting.
3. Review of Resident R189's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED]. The resident discharged on [DATE REDACTED].
Review of Resident R189's discharge MDS located in the MDS tab in the EMR, with an ARD of 10/13/24, revealed a BIMS assessment with a recorded score of 15 out of 15 which indicated no cognitive impairment. Resident R189 had no delirium, no mood, and no behaviors.
On 10/03/24 at approximately 1:52 AM, there was a reported allegation of staff-to-resident abuse between Resident R188 and CNA50. The family member of Resident R188 (FM) 2 was also documented in the facility at this time.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609 Record review revealed a Progress Note in the Progress Note tab for Resident R188, dated 10/03/24 at 7:52 AM, revealed, .(FM2) verbally abused resident roommate (Resident R189), stated angry black woman .used profanity Level of Harm - Minimal harm or towards resident roommate (Resident R189). potential for actual harm
Review of the Facility Incident Report form, dated 10/03/24, revealed that on 10/03/24 at approximately Residents Affected - Few 10:32 AM, Resident R188 was documented to have thrown a full bottle of Gatorade at Resident R189 and call her names. The police, physician, responsible, and Ombudsman were notified.
Review of the Administrator email to the State agency revealed the incident was State reported as an allegation of potential abuse on 10/03/24 at 8:34 PM, about 10 hours after the facility became aware of the incident.
During an interview on 05/22/25 at 6:58 AM, the Administrator stated that he did not have documentation that
the incident of potential verbal abuse between Resident R188's family member and Resident R189 had been reported. He confirmed that if FM2 had come in and was verbally abusive to Resident R189 there should have been a reportable incident to the State agency for that, which there was not. He said he did not know why he was not informed of the potential allegation of staff-to-resident abuse between Resident R188 and CNA50 by the staff at the time of the incident which was 1:52 AM. He confirmed he should have been informed timely. The Administrator stated that the nurse on duty also did not inform him timely and was also no longer working at the facility.
During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations stated that if a police officer came to the facility, even after regular hours, the Administrator should be alerted and notified timely. Upon reviewing the witness statements from the incident between Resident R189 and the resident representative of Resident R188, she confirmed that the potential verbal abuse by FM2 against Resident R189 should have been reported and investigated.
During an additional interview on 05/22/25 at 3:14 PM, the Regional Director of Clinical Operations confirmed that the potential allegation of visitor-to-resident verbal abuse between Resident R189 and FM2 was not reported.
During an interview on 05/22/25 at 3:22 PM, the Director of Nursing (DON) stated that she wanted to see any allegations of abuse reported right away, any physical abuse, financial exploitation, misappropriation of funds, any abuse, as soon as possible. She confirmed it should be reported within a two-hour window. She stated she would have wanted to see the incident between the family member of Resident R188 verbally yelling at Resident R189 be reported to the State agency for investigation.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26446 potential for actual harm Based on staff interviews, record review, and facility policy review, the facility failed to conduct a thorough Residents Affected - Few investigation for incidents of potential abuse for three of nine residents (Resident (R) 136, Resident R188, and Resident R189) reviewed out of 28 sampled residents, for potential staff-to-resident abuse for Resident R136 and Resident R188, and visitor-to-resident abuse for Resident R189. The failure to investigate potential allegations of abuse for facility residents placed all residents at risk of abuse.
Findings include:
Review of the facility's policy titled, Abuse Prevention Policy, last revised 03/01/18, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .When abuse, neglect or exploitation is suspected the Licensed Nurse should: .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Once the resident is cared for and the initial reporting has occurred, an investigation should be conducted. Components of an investigation may include interview with the involved resident, if possible, and document all responses .Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to policy. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. Ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made .
1. Review of the Facility Incident Report form, dated 10/03/24, revealed that the resident representative for Resident R188 reported to the police that Certified Nursing Assistant (CNA)50 allegedly slapped Resident R188 twice to the right side of her face. Police were present at the facility, the responsible party, and Ombudsman were notified of the allegation. The CNA was suspended pending the outcome of the allegation.
Continued review of the investigation revealed a witness statement from the 10/03/24 incident with CNA50, dated 10/02/24 (sic), stated, Resident R188 was receiving care and started to have behaviors in the middle of changing her .She started spitting, hitting, and screaming and disturbing her roommates.
There was no evidence that a complete investigation was completed of the incident between Resident R188 and CNA50. Witness statements were completed only for the roommates of Resident R188, and two CNAs at the facility. No additional staff members were interviewed for the investigation to determine if there were any other potential staff-to-resident abuse situations from CNA50. Additional residents from the facility were not interviewed to determine if they felt safe residing on the same unit with Resident R188, or if they had experienced any staff-to-resident abuse from CNA50.
The failure to do a complete and thorough investigation of the 10/03/24 staff-to-resident abuse allegation between Resident R188 and CNA50 additionally led to the failure to do a thorough investigation of the visitor-to-resident verbal abuse between Resident R189 and Family Member (FM)2. This was documented in the resident record for Resident R188 as verbal abuse of Resident R189 but was not reported nor investigated.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 During an interview on 05/22/25 at 6:58 AM, the Administrator stated that he did not have documentation that
the incident of potential verbal abuse between FM2 and Resident R189 had been reported. He confirmed that if FM2 Level of Harm - Minimal harm or had come in and was verbally abusive to Resident R189 there should have been a reportable incident to the State potential for actual harm agency for that, which there was not. He stated that he had not been made aware that resident witness statements from Resident R189 and Resident R62 had stated that FM2 had been in the resident room and had been verbally Residents Affected - Few abusive with Resident R189. The Administrator said that he had interviewed other residents after the staff-to-resident abuse allegation between Resident R188 and CNA50 but had not documented any of those additional interviews. He confirmed he was not aware if he should have documented more interviews during the alleged incident of abuse.
During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations upon reviewing the witness statements from the incident between Resident R189 and FM2, she confirmed that the potential verbal abuse by FM2 against Resident R189 should have been reported and investigated.
During an additional interview on 05/22/25 at 3:14 PM, the Regional Director of Clinical Operations confirmed
the potential allegation of visitor-to-resident verbal abuse between Resident R189 and FM2 was not thoroughly investigated. She stated that a complete abuse investigation should include speaking with all assigned staff at the time of the incident, and to get written statements. She said even if staff were not working on the same floor, the staff could still be interviewed to see what they were aware of. She said she expected residents to be interviewed from the same room, and in the area to see if they heard anything or saw anything. The Regional Director of Clinical Operations said that she would want all the information she could get from residents and staff.
During an interview on 05/22/25 at 3:22 PM, the Director of Nursing (DON) stated that for a thorough abuse investigation it would definitely include to first ensure the patient was safe. She said the person suspected of possible abuse would be off work. She confirmed that the investigation would then be to get statements, follow-ups, and check equipment. She stated that they would do patient interviews, and see what the outcomes were, and to see if any other residents or staff were involved. The DON said she would want to make sure they had not left anything out. She stated she would have wanted to see the incident between FM2 verbally yelling at Resident R189 be reported to the State agency for investigation.
2.Review of a Facility Incident Report, dated 03/06/25 revealed Type of Incident-Neglect .Details of Incident . [name of Resident R136] is alleging that Certified Nursing Assistant (CNA) 48 neglected him by not turning him timely.
Review of the facility's Facility Follow Up Investigation, dated 03/13/2025 revealed . [name of Resident R136] alleged that [name of CNA48] neglected him by not turning him timely . [name of Resident R136] said he called and requested assistance at 2:03 AM on March 6, 2025. He said the CNA did not come to his room until 6:30 AM. When [name of CNA 48] was interviewed, she said she did not go in until 6:30 AM as she felt the resident was rude . The facility conclusion revealed It was determined that the accusation of neglect was Substantiated . Further review of the facility's investigation revealed written statements were obtained from Registered Nurse (RN) 2, a phone interview with CNA48, and 11 additional resident interviews were conducted; however, there was no investigation conducted as to why RN2 did not assist Resident R136 with turning at 2:00 AM, or anytime
during the night.
Review of Resident R136's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed Resident R136 was admitted to the facility on [DATE REDACTED].
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 Review of the Resident R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to Level of Harm - Minimal harm or have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was potential for actual harm cognitively intact.
Residents Affected - Few Review of Resident R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15 which indicated the resident was cognitively intact.
During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, when asked why the facility did not consider neglect on part of RN2 or consider this as part of the facility investigation, the DON stated, I agree it would be neglect on part of the nurse [RN2] 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. She as
the nurse could have gone in his room to turn him.
During an interview on 05/21/25 at 1:00 PM the Administrator stated I see where it was neglect on part of the nurse as well when this happened. She could have gone into his [referring to Resident R136] room and turned him. When the Administrator was asked why the facility did not conduct a thorough investigation and investigate why RN2 did not go in Resident R136's room to turn him during the night, he stated, We did not look into why the nurse did not go in and turn him. That was not part of our investigation. It should have been investigated, and
it was not.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33865
Residents Affected - Few Based on record review, staff interviews, and facility policy review, the facility failed to ensure a complete discharge summary was provided to the resident and/ or resident representative (RP) for one of three residents (Resident (R) 338) reviewed for discharges of 46 sample residents. This failure had the potential to affect the residents and/or representatives' knowledge of the residents' discharge plan.
Findings include:
Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed Orientation for Transfer or Discharge (Planned) 1. A post-discharge plan is developed for each resident prior to his or her discharge. This plan will be reviewed with the resident, and/or his or her family, at least 24 (24) hours before the resident's discharge or transfer from the facility.
Review of Resident R338's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted [DATE REDACTED] and the date of discharge was 12/19/24.
Review of Resident R338's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated Resident R338 was cognitively intact.
Review of Resident R338's Discharge Summary and Instructions located under the Assessment tab of the EMR, dated 12/19/24, revealed the following missing components:
-2A. Psychosocial Status of the Resident (Social Services) - Blank and unsigned.
-2B. Preparation for Discharge and Post Discharge Care (Social Services) - Blank and unsigned.
During an interview on 05/20/25 at 1:17 PM, Licensed Practical Nurse (LPN) 3 stated she did not know the resident, but she filled out her section of the discharge summary. LPN3 also stated the Social Service Director's (SSD) portion of the discharge summary was not completed. She stated she faxed it to the resident's daughter. She confirmed the summary was not complete.
During an interview on 05/20/25 at 1:39 PM, the Social Services Director (SSD) stated the discharge summary needed to be completed and then provided to the resident and family. She stated she did not see that the resident received any home health services and did not see where a discharge date was picked. She stated she started in this position in early January 2025 and was not here during this time. She confirmed the discharge summary was not fully complete and she stated she was not able to find the recapitulation summary of the resident's stay.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641 Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39540 potential for actual harm Based on observation, record review, staff interviews, and review of the Resident Assessment Instrument Residents Affected - Few (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 46 sampled residents (Resident (R) 9 and Resident R18). Failure to code the MDS correctly regarding Resident R18's feeding tube, and Resident R9 for hospice care, could lead to inaccurate assessment and care planning of the resident.
Findings include:
Review of the RAI Manual, dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that
observation period) by the IDT completing the assessment .
1. Review of Resident R9's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE REDACTED] and a readmitted [DATE REDACTED], with medical diagnoses that included adult failure to thrive and unspecified dementia.
Review of Resident R9's Physician order, dated 12/04/24 and located under the Orders tab in the EMR revealed a hospice wound order
Review of Resident R9's annual MDS with an Assessment Reference Date (ARD) of 03/14/25 and located in the resident's EMR under the MDS tab revealed the facility failed to document Resident R9 was receiving hospice services.
2. Review of Resident R18's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED] with medical diagnoses including encounter for attention to gastrostomy (G-Tube) and dysphasia following cerebral infarction.
Review of Resident R18's Physician order, dated 04/16/25 revealed orders for enteral feeding through G-Tube and medications were to be administered through the G-Tube.
Review of Resident R18's admission MDS with an ARD of 04/30/25 and located in the resident's EMR under the MDS tab revealed during the assessment, the facility failed to document Resident R18 had a G-Tube and was receiving nutrition and medication through the G-Tube.
During an interview on 05/20/25 at 2:01 PM, the MDS Coordinator (MDSC) reviewed Resident R9's and Resident R18's MDS and confirmed the MDS did not indicate Resident R9 was receiving hospice services; and that Resident R18's MDS was not accurate as it did indicate the resident had a G-Tube.
During an interview on 05/22/25 at 5:04 PM, the Regional Director of Clinical Operations (RDCO) confirmed
the facility using the RAI manual for accuracy of MDS assessments.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39540
Residents Affected - Few Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure care plans were comprehensively developed for two of 46 sampled residents (Resident (R) 18 and Resident R52) reviewed for care plans. This deficient practice placed the residents at risk for unmet care needs.
Findings include:
Review of the facility policy titled Care Plan-Comprehensive, dated 01/23, revealed A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to: . identify the professional services that are responsible for each element of care; . Incorporate risk factors associated with identified problems.
1. Review of Resident R18's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE REDACTED] with medical diagnoses including encounter for attention to gastrostomy (G-Tube) and dysphasia following cerebral infarction.
Review of Resident R18's admission Minimum Data Set (MDS) with an ARD of 04/30/25 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident R18 was cognitively intact.
During an observation on 05/20/25 at 4:38 PM, Resident R18 was lying in bed. Licensed Practical Nurse (LPN) 9 was
in the resident's room administering medication via the resident's G-tube.
During an interview on 05/21/25 at 7:45AM, Resident R18 expressed a preference to have medications administered through the G-Tube and not by mouth because the medications tasted bitter.
Review of Resident R18's Care Plan under the Care Plan tab initiated 04/17/25 in the EMR lacked documentation of a focus for G-tube care.
During an interview on 05/20/25 at 2:01 PM, the MDS Coordinator (MDSC) stated that there should have been a care plan developed related to Resident R18's G-tube care, administration of medications, and nutrition.
During an interview on 05/21/25 at 10:41 PM, the Director of Nursing (DON) confirmed residents with a g-tube should have a care plan for resident's plan of care.
2. Review of Resident R52's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE REDACTED] with medical diagnoses including unspecified dementia with psychotic disturbance, and delusional disorders.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Review of Resident R52's Physician Orders located in the resident's EMR under the Orders tab revealed physician orders dated 01/22/25 for Seroquel [an antipsychotic] Oral Tablet 25 MG (quetiapine fumarate) Give 1 tablet Level of Harm - Minimal harm or by mouth two times a day for Psychotic disorder due to known physiological condition and sertraline [an potential for actual harm antidepressant] HCl Oral Tablet 50 MG (sertraline HCl) Give 1 tablet by mouth one time a day related to unspecified dementia with psychotic disturbance and delusional disorders. Residents Affected - Few
Review of Resident R52's Care Plan under the Care Plan tab in the EMR lacked documentation of a plan of care for
the resident's psychotropic medications to include antipsychotic and antidepressant medications.
During an interview on 05/22/25 at 12:41 PM, the MDSC confirmed Resident R52 did not have a care plan related to psychotropic medication and antipsychotic medications, including monitoring of behaviors and care needed.
During an interview on 05/22/25 at 12:44 PM, the Director of Nursing (DON) confirmed residents on psychotropic medications should have a care plan focus when on the medications.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33865 potential for actual harm Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure Residents Affected - Few timely medication administration for one of seven residents (Resident (R) 286) reviewed for medication administration of 46 sample residents. The facility further failed to ensure physician orders were followed for
the administration of medications using the gastrostomy (G-Tube) for one of six residents (Resident (R) 18).
This had the potential for creating anxiety to the resident and possible medication administration errors or choking.
Findings include:
Review of the facility's policy titled, Administering Medications, dated 04/19, revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.
1.Review of Resident R286's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE REDACTED] and had a discharge date of [DATE REDACTED] with diagnoses which included chronic obstructive pulmonary disease, asthma, hemiplegia (one sided paralysis) and hemiparesis (one-sided muscle weakness), and unspecified combined systolic (congestive) and diastolic (congestive) heart failure.
Review of Resident R286's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident R286 was cognitively intact.
Review of the Medication Admin Audit Report, provided by the facility and dated 01/01/25- 01/18/25, revealed the following:
-01/08/25 for methocarbamol oral tablet 500 MG [milligram]: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/08/25 at 17:00 (5:00 PM) with the Administration Time: 01/08/25 at 19:58 (7:58 PM).
-01/10/25 for Spiriva HandiHaler Inhalation Capsule 18 MCG [microgram]: 1-capsule inhale orally one time a day related to other asthma. Schedule date: 01/10/25 at 7:00 (7:00 AM) with the Administration Time: 01/10/25 at 10:38 AM.
-01/11/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/11/25 at 9:00 AM with the Administration Time: 01/11/25 at 11:03 AM.
-01/12/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/12/25 at 9:00 AM with the Administration Time: 01/12/25 at 13:09 (1:09 PM).
-01/14/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/14/25 at 17:00 (5:00 PM) with the Administration Time: 01/14/25 at 19:04 (7:04 PM).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 -01/16/25 for ipratropium-albuterol inhalation solution 0.5-2.5 MG/3ML [milligram/milliliter]: 1-vial inhale orally every 6-hours related to chronic obstructive pulmonary disease with (acute) exacerbation. Schedule date: Level of Harm - Minimal harm or 01/16/25 at 00:00 with the Administration Time: 01/16/25 at 5:54 AM. potential for actual harm -01/17/25 for ipratropium-albuterol inhalation solution 0.5-2.5 MG/3ML: 1-vial inhale orally every 6-hours Residents Affected - Few related to chronic obstructive pulmonary disease with (acute) exacerbation. Schedule date: 01/17/25 at 00:00 with the Administration Time: 01/17/25 at 4:56 AM.
-01/17/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:32 (1:32 PM).
-01/17/25 for aspirin EC low strength oral tablet delayed release 81 MG: Give 1-tablet by mouth one time a day related to cerebral infarction. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:26 (1:26 PM).
-01/17/25 for hydrochlorothiazide oral tablet 15 MG: give 1-tablet by mouth one time a day related to unspecified combined systolic congestive and diastolic (congestive) heart failure. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:26 (1:26 PM).
-01/17/25 for atorvastatin calcium oral tablet 40 MG: Give 1-tablet by mouth one time a day for hemiplegia and hemiparesis. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:27 (1:27 PM).
-01/18/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/18/25 at 17:00 (5:00 PM) with the Administration Time: 01/18/25 at 19:56 (7:56 PM).
Review of the performance improvement plan worksheet (PIP) provided by the facility and dated 03/18/25, revealed medications not being administered on time by nurses/ CMAs [Certified Medication Aide Tech]. Identify root causes: 1. Lack of education .Design and implement changes.1. Inservice all nurses and CMA's regarding proper time management.
Reviews of the Education In-service Attendance Record, provided by the facility and dated 03/18/25, revealed three out of the five staff (Activity Director/ Medication Aide Tech), Licensed Practical Nurse (LPN) 5, and LPN8, identified as administering medications late were not on the list as educated.
During an interview on 05/21/25 at 1:47 PM, the Director of Nursing (DON) stated the medication administration should be one-hour before to one-hour after the time displayed. She confirmed the late medications were out of policy and unacceptable.
2. Review of Resident R18's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE REDACTED] with medical diagnosis including encounter for attention to gastrostomy (G-Tube).
Review of Resident R18's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/05/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident R18 was cognitively intact.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Review of Resident R18's physician Orders dated 04/16/25 located in the EMR under the Orders tab revealed medications were to be crushed and administered through the G-Tube. Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record (MAR) located in the EMR for May 2025 documented medications were administered on 15-day shifts by Certified Medication Aide Tech (CMAT) 1. Residents Affected - Few
During an interview on 05/21/25 at 9:19 AM, CMAT confirmed the role of the CMAT was to administer oral medications and not to administer by G-Tube. The CMAT confirmed all the medications she had administered to Resident R18 were by mouth and was not according to physician's orders.
During an interview on 05/21/25 at 9:09 AM, the Licensed Practical Nurse (LPN)2/Charge Nurse confirmed
the role of the CMAT was for oral medications only and not to administer by G-Tube. LPN2 confirmed CMAT1 had not requested LPN2 to administer medications for Resident R18 by G-Tube as CMAT1 was administering
the medications by mouth for Resident R18. LPN2 confirmed the physician's order for medication administration for Resident R18 was by G-Tube and not by mouth and CMAT1 was not following the physician's orders.
During an interview on 05/21/25 at 7:45 AM, Resident R18 expressed the desire to have all the medications delivered by the G-Tube and not by mouth due to the medication taste.
During an interview on 05/22/25 at 4:50 PM, the Director of Nursing (DON) confirmed the physician's orders were to be followed, including medication orders, for the residents.
Review of the facility policy titled Administering Medications, revised 04/19, revealed Medications were administered in accordance with prescriber orders .Medication administration times are determined by resident need and benefit, not staff convenience. Factors that were considered include: . honoring resident choices and preferences, consistent with his or her care plan.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685 Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26446 potential for actual harm Based on resident and staff interviews and record review, the facility failed to ensure residents received Residents Affected - Some proper treatment and services to maintain vision and hearing abilities for one of two residents reviewed for communication (Resident (R) 22) out of 46 sampled residents. The failure to ensure communication deficits were properly assessed and managed placed the facility residents at risk of social isolation.
Findings include:
Review of Resident R22's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed
he was originally admitted on [DATE REDACTED], with diagnoses including non-Hodgkin lymphoma, hypertension, and diabetes mellitus.
Review of Resident R22's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 03/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The MDS also revealed Resident R22 was documented to have minimal difficulty in hearing, which indicated some hearing difficulty in some environments.
Review of Resident R22's Care Plan, located in the EMR under the Care Plan tab, with an initiated date of 12/12/21, revealed a care plan for a communication problem related to hearing deficit. Approaches included .to ensure availability and functioning of adaptive communication equipment: message board .hearing aids .refer to Audiology for hearing consult as ordered .
Review of Resident R22's Audiology Assessment, dated 09/30/24 and located in the resident's EMR under the Misc tab documented, The patient was referred by the facility for decreased hearing. The patient complains of hearing loss .She had a hearing aide [sic] for the right ear .but reports it stopped working/helping .A pocket talker is going to be requested for this patient at this time.
During an interview on 05/19/25 at 10:49 AM, Resident R22 stated that she could not hear well. She stated that she used to have hearing aids, but they were lost a long time ago. Resident R22 said that if she could hear better, it would be easier to understand what people say. She said that someone said they would look into it for her, but they never got back to her.
During an interview on 05/21/25 at 7:35 AM, Certified Nursing Assistant (CNA) 9 stated she had not seen Resident R22 use a hearing device and confirmed the resident was hard of hearing. Upon entrance to Resident R22's room, CNA9 spoke loudly into Resident R22's ear to ask if she had a hearing device. Resident R22 asked CNA9 to look in her purse, where a single hearing aid was found. Resident R22 said it did not work. CNA9 said she had not seen Resident R22 use any hearing devices.
During an interview on 05/21/25 at 7:38 AM, Licensed Practical Nurse (LPN) 3 stated that she had not seen Resident R22 use any form of hearing device.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685 During an interview on 05/21/25 at 7:44 AM, the Social Service Director (SSD) stated that ancillary service providers come to the facility approximately every quarter and see about 20 residents at a time since they Level of Harm - Minimal harm or could not see them all at once. The SSD also stated she kept a list but was not familiar with Resident R22 having any potential for actual harm hearing issues. Upon review of her list, she stated that Resident R22 had not been seen the last time audiology had come to the facility. After reviewing the 09/30/24 audiology report for Resident R22, the SSD stated she had not been Residents Affected - Some familiar with the recommendation for a pocket talker and would look into it.
During an interview on 05/21/25 at 11:00 AM, the Director of Nursing (DON) stated that the last SSD had left
the facility in January 2025, before the current one had started. She confirmed that the last SSD had not always followed up on things, and that she would expect there to be better communication with ancillary services.
During an interview on 05/21/25 at 12:55 PM, the SSD stated she had discovered that Resident R22's invoice for the pocket talker had not been paid, and that it was why it had not been provided to the resident.
During an interview on 05/21/25 at 1:47 PM, the DON stated that the facility did not have a policy regarding ancillary services.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26446
Residents Affected - Few Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure residents with a urinary catheter bag were properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of three residents (Resident (R)10) reviewed for urinary catheters out of a total sample of 46 residents. The failure to ensure catheter bags were properly positioned placed the resident at risk of infection.
Findings include:
Review of the facility's undated policy titled, Indwelling Urinary Catheter Use, revealed It is the policy of the facility to ensure the appropriate use of indwelling urinary catheters in accordance with State and Federal Regulations, and national guidelines .Indwelling urinary catheters and drainage bags should not be changed at routine or fixed intervals. Indwelling urinary catheters and drainage bags are changed when there is indication of infection, obstruction, or as clinically indicated.
Review of Resident R10's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed
he was originally admitted on [DATE REDACTED] with diagnoses including multiple sclerosis, other sequelae of cerebral infarction, and pressure ulcer of sacral region.
Review of Resident R10's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/25and located in the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) assessment with no recorded score out of 15, which indicated severe cognitive impairment. Resident R10 was documented to require a catheter.
Review of Resident R10's Physician Orders located in the EMR under the Orders tab revealed a order dated 04/16/25 for Change indwelling Foley Cath [Catheter] 16 F [French]/10 ml [milliliters] every month and PRN [as needed] every day shift every 28 day(s) .
Review of Resident R10's Care Plan, initiated 04/16/25 and located in the resident's EMR under the Care Plan tab revealed the resident had an indwelling foley catheter related to sacrum end stage skin failure. Interventions dated 04/16/25 revealed .position catheter bag and tubing below the level of the bladder and away from the entrance room door, and to monitor and document the intake and output as per facility policy.
During an observation on 05/19/25 at 10:25 AM, Resident R10 was lying in bed with her eyes closed. Resident R10's uncovered indwelling catheter collection bag was hanging from the right side of the resident's bed, resting on the floor.
During an observation on 05/19/25 at 12:12 PM, Resident R10 was lying in bed with her eyes closed. The catheter bag was still in the same position, resting uncovered on the floor.
During an observation on 05/20/25 at 8:12 AM, Resident R10 was observed resting in bed. The catheter bag was again observed uncovered and resting on the floor.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690 During an observation on 05/20/25 at 9:50 AM, Resident R10 was lying in her bed resting. The catheter bag was observed uncovered and resting on the floor. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 05/20/25 at 9:51 AM, Licensed Practical Nurse (LPN) 2 and LPN3 stated that catheter bags should be kept off the floor. LPN2 observed Resident R10 in bed, and confirmed the catheter Residents Affected - Few bag was resting on the floor. LPN3 stated that a staff member must have lowered the resident's bed and proceeded to raise the resident's bed. The urinary catheter tubing stretched, but the catheter bag did not rise off the floor because the bag was not hooked to the bed.
During an interview on 05/20/25 at 10:18 AM, the Regional Director of Clinical Operations (RDCO) stated that she expected urinary catheter bags to be hung off the floor.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39540 Residents Affected - Few Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a resident with side rails was assessed for entrapment, evaluated for need, informed of the risks/benefits, and failed to obtain a physician's order for side rail use for one of one residents (Resident (R) 20) reviewed for side rails out of a total sample of 46 residents in the sample. This had the potential for safety risks to the resident.
Findings include:
Review of the facility policy titled Bedrails, with no revision date, revealed, The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. a. Assess the resident for risk of entrapment from bed rails prior to installation. b. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. When bed/side rails are deemed to be appropriate for the resident, upon completion of the Side Rail Evaluation, the . nurse will review risks and benefits, obtain informed consent and obtain an order to monitor the resident while in bed with side rails were in use.
Review of Resident R20's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE REDACTED].
Review of Resident R20's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/21/25, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating Resident R20 was moderately impaired in cognition.
During an observation on 05/19/25 at 10:58 AM, Resident R20 was in bed with side rails on each side of the bed in the up position.
During an interview on 05/20/25 at 11:53 AM, Certified Nursing Assistant (CNA)15 said Resident R20 used the rail to assist herself and the staff when sitting on the side of the bed.
Review of Resident R20's Bed Environment Assessment, located under the Assessments tab in the EMR, dated 08/19/24, revealed documentation that no bed rails were in use.
Review of Resident R20's Misc tab for scanned documents in the EMR, lacked documentation of a consent form for
the use of side rails.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700 During an interview on 05/20/25 at 11:59 AM, Unit Manager Licensed Practical Nurse (LPN)3 confirmed a resident with side rails was to have a side rail assessment for use, obtain consent from the resident or the Level of Harm - Minimal harm or representative, and obtain a physician's order for the side rail(s). LPN3 verified Resident R20 did have side rails in potential for actual harm place and the EMR lacked a current bed assessment, physician's order, or a consent for the use of side rails.
Residents Affected - Few During an interview on 05/21/25 at 10:14 AM, the Director of Nursing (DON) confirmed if a resident had side rails in place, there should be a bed rail assessment, physician's order and signed consent listing the risks and benefits for side rail use.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0732 Post nurse staffing information every day.
Level of Harm - Potential for 20402 minimal harm Based on observations, staff interview, document review, and facility policy review, the facility failed to post Residents Affected - Many completed up-to-date and current nurse staffing information to include the current date, and the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs). This had
the potential to affect all 83 residents residing in the facility. By not having current and up-to-date information posted it is unclear how many staff were available to care for the number of residents in the facility each day.
Findings include:
Review of the facility's policy review titled, Instructions for Completing Nurse Staffing Information Form, dated August 2022 indicated Completing this Form- 1. Complete the Nurse Staffing Information form within 2 hours of the beginning of each shift. It further indicated, Posting the Information-1. Print the completed form in a clear and readable format every shift. 2. Post in a prominent place that is readily accessible to residents and visitors. 3. Post with the information form the prior shift(s) so that information on staffing for the previous 24 hours is visible.
Review of the facility's policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022 indicated Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.
During an observation on 05/19/25 at 9:00 AM of the most current and up-to-date staffing information posted
on the wall in a clear plastic 8 inches by 11 inches frame across from the receptionist desk at the front entrance of the facility was dated Tuesday 05/13.25. (This was identified to be seven days prior to the survey entrance beginning on 05/19/25). The current census was listed as 82 residents. There was no documentation of the actual hours being worked for licensed and unlicensed staff to include RNs, LPNs, or CNAs.
During an interview on 05/20/25 at 2:04 PM, regarding the posting of the daily staffing, and reviewing the staffing document dated 05/13/25, that was posted at the front entrance of the facility when the survey team entered the facility on 05/19/25 at 9:00 AM, the Director of Nursing (DON) stated, Yes, our daily staffing should be updated and posted daily. I would expect it should also have the correct information with the right date, what the current census is, and our staffing numbers. Our staffing coordinator would be the one to ensure the posting of the daily staffing at the front entrance. The DON stated, My expectation would be that our daily staffing schedule is posted with current date and information first thing in the morning at 8:00 AM if not before.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26446
Residents Affected - Few Based on staff interviews, record review, and review of facility policy, the facility failed to ensure residents reviewed for verbal and physical abuse had accurate documentation of the abuse incidents in the resident
record for one of nine residents (Resident (R) 189) reviewed for abuse out of a total of 46 resident in the sample. The deficient practice had the potential for facility residents to not be identified for potential incidents of abuse, which could affect physical and psychosocial well-being.
Findings include:
Review of the facility's policy titled, Medical Records, dated 08/2022, revealed It is the policy of the facility to maintain Medical Records in accordance with State and Federal Regulations .The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, systematically organized.
Review of Resident R189's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED].
The resident discharged on [DATE REDACTED].
Review of Resident R188's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE REDACTED].
The resident was discharged on [DATE REDACTED].
Facility provided documentation, and resident record review, revealed two incidents of potential abuse with Resident R189.
-On 10/03/24 at approximately 1:52 AM, a resident representative (Family Member (FM)2) for Resident R188 was noted to be in the facility due to an allegation of staff to resident abuse between Resident R188 and Certified Nursing Assistant (CNA)50. During this incident, statements from Resident R189 and Resident R62, both roommates of Resident R188, revealed verbal abuse and name calling from Resident R188's resident representative against Resident R189.
-On 10/03/24 at approximately 10:32 AM, Resident R188 was documented to have thrown a full bottle of Gatorade at Resident R189 and call her names.
Both incidents were documented and recorded in the Progress Notes tab in the EMR, but only in the resident
record for Resident R188, but not for Resident R189. Neither incident was documented in Resident R189's complete record review.
During an interview on 05/22/25 at 6:58 AM, the Administrator confirmed that upon review of Resident R189's record, there was no documentation of the abuse incidents in her resident record.
During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations stated that she would expect to see documentation in Resident R189's resident record regarding the verbal abuse incident on 10/03/24 at approximately 1:52 AM. She confirmed this would be a documentation failure in the resident's record.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 115674 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115674 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Westminster Commons 560 St Charles Ave, NE Atlanta, GA 30308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 During an interview on 05/22/25 at 12:25 PM, the Director of Nursing (DON) stated that if there was any altercation or incident including residents, both resident records should be documenting the concern to Level of Harm - Minimal harm or ensure complete and accurate records. potential for actual harm Cross reference to