Inspection Reports for Westbury Center of Conyers for Nursing and Healing
1420 MILSTEAD ROAD, CONYERS, GA, 30012
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 8, 2024, found no deficiencies related to the complaints investigated, all of which were unsubstantiated. Prior inspections showed a pattern of deficiencies primarily involving resident care issues such as pain management and activities of daily living, as well as life safety code violations including obstructed egress and fire safety equipment concerns. Earlier complaint investigations included some substantiated cases without deficiencies and one substantiated complaint related to incomplete injury investigations. Enforcement actions such as immediate jeopardy findings and fines were not listed in the available reports. The facility appears to have addressed prior deficiencies effectively, with recent re-inspections confirming corrections and no new citations noted in the latest survey.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
156 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 156
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00248389, GA00249054, GA00249129, and GA00249206.
Complaint Details
Complaints GA00248389, GA00249054, GA00249129, and GA00249206 were investigated and found to be unsubstantiated.
Findings
No deficiencies were cited related to the complaints investigated, and all complaints were found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Westbury Center of Conyers for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 151
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the May 10, 2024 Recertification Survey. Additionally, a complaint investigation (GA00247774) was conducted in conjunction with this revisit.
Complaint Details
Complaint Intake Number GA00247774 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the May 10, 2024 Recertification Survey were found to be corrected. The complaint investigation revealed that the complaint was unsubstantiated.
Report Facts
Census: 151
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the follow-up survey.
Inspection Report
Re-Inspection
Census: 151
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
A revisit survey was conducted on July 2, 2024, to verify correction of deficiencies cited in the May 10, 2024 Recertification Survey and to investigate Complaint Intake Number GA00247774.
Complaint Details
Complaint Intake Number GA00247774 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the May 10, 2024 Recertification Survey were found to be corrected. The complaint investigation revealed that Complaint Intake Number GA00247774 was unsubstantiated.
Report Facts
Census: 151
Inspection Report
Renewal
Deficiencies: 2
Date: May 10, 2024
Visit Reason
The inspection was a Licensure Survey conducted from May 6, 2024 through May 10, 2024 to assess compliance with licensure requirements.
Findings
The facility failed to provide adequate pain management to resident R117, who exhibited signs of pain and distress but was only given Tylenol despite having an order for stronger medication. Additionally, the facility failed to provide proper activities of daily living (ADL) care for resident R4, resulting in inadequate nail care and hand hygiene.
Deficiencies (2)
Failure to ensure pain management was provided to resident R117, who exhibited physical signs and symptoms of pain and distress but was only given Tylenol instead of stronger prescribed medication.
Failure to provide adequate activities of daily living (ADL) care for resident R4, resulting in inadequate nail care and hand hygiene.
Report Facts
Residents reviewed for pain management: 6
Residents reviewed for ADL care: 5
Medication doses administered: 3
Medication doses administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed during medication pass and involved in care of resident R117. |
| LPN NN | Licensed Practical Nurse | Nurse Supervisor involved in resident care and interviewed regarding ADL protocols. |
| LPN OO | Licensed Practical Nurse, Wound Care Nurse | Discussed protocol for managing resident pain during medication passes. |
| CNA PP | Certified Nursing Assistant | Confirmed inadequate hand and nail care for resident R4. |
| Administrator | Provided status updates on resident R117. |
Inspection Report
Annual Inspection
Census: 148
Capacity: 173
Deficiencies: 7
Date: May 10, 2024
Visit Reason
A standard annual survey was conducted from May 6, 2024 through May 10, 2024, including investigation of multiple complaint intake numbers.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Several intake numbers were unsubstantiated, some substantiated without deficiencies, and others substantiated with deficiencies including those related to pain management and code status documentation.
Findings
The facility was found not in compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely assess and medicate a resident in pain resulting in hospital admission, failure to have accurate code status documentation, inadequate ADL care, failure to provide proper urostomy care, medication errors, inaccurate staffing data reporting, and infection control lapses.
Deficiencies (7)
Failure to timely assess and medicate resident R117 in pain, resulting in hospital admission with colitis.
Failure to have consistent and accessible code status documentation for resident R111.
Failure to provide adequate activities of daily living care including nail and hand hygiene for resident R4.
Failure to ensure urostomy care was provided consistent with professional standards; resident R262 sent to appointment without urostomy bag.
Medication error rate of 11.11% observed for resident R124 with medications administered outside scheduled times.
Failure to accurately report direct care staffing data to CMS, resulting in a One-Star Staffing Rating for Q1 2024.
Failure to follow infection control practices including handling medications with bare hands and not bagging respiratory equipment when not in use.
Report Facts
Medication opportunities observed: 27
Medication errors observed: 3
Medication error rate: 11.11
Licensed bed capacity: 173
Census: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Administered medications too early and handled medications with bare hands during medication administration |
| LPN AA | Licensed Practical Nurse | Observed failing to timely assess and medicate resident R117 in pain |
| Director of Nursing | Director of Nursing | Provided expectations regarding code status documentation and infection control practices |
| Administrator | Administrator | Provided statements regarding facility policies and staffing issues |
| LPN OO | Wound Care Nurse | Discussed protocol for managing resident pain during medication passes |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed medication administration timing protocols and infection control expectations |
Inspection Report
Life Safety
Census: 146
Capacity: 173
Deficiencies: 3
Date: May 7, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructed means of egress, a loaded sprinkler head in the laundry area, and electrical panels lacking proper circuit identification. These deficiencies affect one of five smoke compartments.
Deficiencies (3)
Failed to maintain clear unobstructed means of egress; multiple items such as diagnostic carts, soiled linen carts, and patient lifts obstructed egress.
Failed to maintain sprinkler system in optimum readiness; a sprinkler head in the laundry area was found loaded.
Failed to assure electrical panels were maintained with proper circuit identifications; a small extension electrical panel in the kitchen lacked circuit IDs.
Report Facts
Census: 146
Total Capacity: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited Federal survey tags have been corrected.
Findings
The surveyor noted that all previously cited Federal survey tags have been corrected.
Inspection Report
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the Westbury Center of Conyers for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A revisit survey was conducted on 12/8/22 to investigate Complaint Intake Numbers GA00229640 and GA00229946 in conjunction with a previous recertification, complaint investigation, and state licensure survey.
Complaint Details
Complaint GA00229640 was unsubstantiated; complaint GA00229946 was substantiated with no deficiencies.
Findings
All deficiencies cited from the 10/6/22 recertification and complaint investigation were found to be corrected. Complaint GA00229640 was unsubstantiated, and complaint GA00229946 was substantiated with no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A revisit survey was conducted on 12/08/22 to verify correction of deficiencies cited during the 10/6/22 Recertification survey conducted in conjunction with a Complaint Investigation and State Licensure Survey.
Complaint Details
Complaint Intake Number GA00229640 was unsubstantiated and complaint GA00229946 was substantiated with no deficiencies.
Findings
All deficiencies cited during the 10/6/22 Recertification and Complaint Investigation were found to be corrected. The complaint investigation found one complaint unsubstantiated and another substantiated with no deficiencies.
Inspection Report
Life Safety
Census: 150
Capacity: 172
Deficiencies: 2
Date: Dec 1, 2022
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted following a state survey agency visit to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was not found in substantial compliance with Life Safety Code requirements, specifically regarding hazardous area enclosures and corridor door hardware. Deficiencies included a medical records room door that was not self-closing and corridor doors lacking positive latching hardware.
Deficiencies (2)
Door to the medical records room was not self-closing or automatic closing, violating hazardous area enclosure requirements.
Corridor doors to the kitchen lacked positive latching hardware and had single cylinder dead bolts installed above the required height.
Report Facts
Certified beds: 172
Census: 150
Number of deficient doors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present when deficiencies related to corridor doors were identified | |
| Maintenance Director | Present when deficiency related to medical records room door was identified |
Inspection Report
Renewal
Census: 151
Deficiencies: 4
Date: Oct 6, 2022
Visit Reason
The inspection was a Licensure Survey conducted from October 3, 2022 through October 6, 2022 to assess compliance with licensure requirements for the nursing facility.
Findings
The facility failed to follow care plans related to weekly weights for two residents and activities of daily living for one resident, including oral care and shaving. There was inconsistent communication with the dialysis center for one resident receiving dialysis. Additionally, the facility failed to properly date and label opened food items in the dry food pantry and did not ensure the oven and ventilation hood were cleaned by the due date.
Deficiencies (4)
Failure to follow care plan related to weekly weights for two residents and activities of daily living for one resident, including oral care and shaving.
Inconsistent communication forms with the dialysis center for one resident receiving dialysis.
Opened food items were not properly dated and labeled in the dry food pantry.
Oven and ventilation hood were not cleaned by the due date of 9/22.
Report Facts
Sample size: 51
Missing Dialysis Communication Forms: 14
Incomplete Dialysis Communication Forms: 18
Census: 151
Weight records missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Interviewed regarding ADL care and documentation |
| CC | Certified Nursing Assistant (CNA) | Interviewed regarding oral care and shaving procedures |
| DD | Certified Nursing Assistant (CNA) | Interviewed and observed providing care to resident #79 |
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding CNA responsibilities and documentation |
| DON | Director of Nursing | Interviewed regarding expectations for resident care and weight program |
| LL | Unit Manager | Interviewed regarding dialysis communication responsibilities |
| Administrator | Interviewed regarding dialysis communication form expectations | |
| Dietary Director | Interviewed regarding food storage and kitchen sanitation | |
| Registered Dietician | Interviewed regarding resident weights and nutritional care |
Inspection Report
Annual Inspection
Census: 156
Deficiencies: 8
Date: Oct 6, 2022
Visit Reason
A recertification survey was conducted from October 3, 2022 through October 6, 2022, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies noted in areas including advance directives documentation, comprehensive care planning, activities of daily living care, nutrition and hydration monitoring, respiratory care, dialysis communication, medication storage security, and food safety and sanitation.
Deficiencies (8)
Failed to ensure code status was consistently documented accurately throughout the clinical record for one resident after a POLST was obtained.
Failed to follow the care plan related to weekly weights for two residents and activities of daily living for one resident.
Failed to provide activities of daily living care related to oral care and shaving for one dependent resident.
Failed to weigh two residents weekly as ordered after significant weight loss.
Failed to follow physician order and ensure humidification was provided for one resident receiving continuous oxygen therapy.
Failed to maintain consistent communication forms with the dialysis center to coordinate care for one resident receiving dialysis.
Failed to ensure two of four medication carts were locked and secured when unattended.
Failed to ensure opened food items were properly dated and labeled in the dry food pantry and failed to ensure the oven and ventilation hood were cleaned by due date.
Report Facts
Resident census: 156
Weight loss percentage: 9.43
Missing dialysis communication forms: 14
Incomplete dialysis communication forms: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Social Service Director | Interviewed regarding code status documentation and POLST process |
| BB | Licensed Practical Nurse | Interviewed regarding ADL care expectations |
| DD | Certified Nursing Assistant | Interviewed regarding ADL care and documentation |
| EE | Licensed Practical Nurse | Interviewed regarding ADL care documentation and expectations |
| LL | Unit Manager | Interviewed regarding dialysis communication responsibilities |
| MM | Certified Nursing Assistant | Interviewed regarding resident weights and documentation |
| KK | Medication Tech | Interviewed regarding oxygen humidification order |
| OO | Licensed Practical Nurse | Interviewed regarding oxygen humidification and placed humidifier on concentrator |
Inspection Report
Life Safety
Census: 150
Capacity: 173
Deficiencies: 0
Date: Oct 5, 2022
Visit Reason
The visit was conducted to review the Emergency Preparedness Program and to perform a Life Safety Code Survey for compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The Emergency Preparedness Program was found to be in compliance with LTC 42 CFR § 483.73. The facility was also found in compliance with the Life Safety Code requirements at 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition.
Report Facts
Census: 150
Certified beds: 173
Inspection Report
Abbreviated Survey
Census: 146
Deficiencies: 0
Date: Apr 20, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00222554, #GA00223258, and #GA00223460.
Complaint Details
Complaint #GA00222554 was substantiated with no deficiencies cited. Complaints #GA00223258 and #GA00223460 were unsubstantiated with no deficiencies cited.
Findings
Complaint #GA00222554 was substantiated with no deficiencies cited. Complaints #GA00223258 and #GA00223460 were unsubstantiated with no deficiencies cited. The facility was found to be in compliance with vaccination requirements for facility staff.
Report Facts
Resident Census: 146
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 25, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00221139 and GA00222315.
Complaint Details
Complaint GA00221139 was unsubstantiated; complaint GA00222315 was substantiated with no citations.
Findings
Complaint GA00221139 was unsubstantiated, and complaint GA00222315 was substantiated with no citations.
Inspection Report
Deficiencies: 0
Date: Mar 23, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Complaint survey of 1/25/2022.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 1/25/2022; all cited deficiencies were found corrected.
Findings
The revisit survey found that all deficiencies cited as a result of the Complaint survey were corrected as of 2/22/2022.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
The visit was conducted as an abbreviated survey to assess licensure compliance at the facility.
Findings
No licensure deficiencies were identified during the abbreviated survey.
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 1
Date: Jan 25, 2022
Visit Reason
The inspection was initiated as an Abbreviated/Partial Extended Survey investigating multiple complaints (GA00220512, GA00219310, GA0021622, GA00219571, GA00217381, GA00214530) and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint GA00219310 was substantiated. The facility failed to thoroughly investigate injuries of unknown origin for three residents (R"A", R#2, and R#3). Investigations did not include all required staff interviews, failed to notify physicians timely, and lacked sufficient documentation. The Administrator and former DON were responsible for incomplete investigations.
Findings
The facility was found in compliance with infection control regulations; however, a substantiated complaint revealed failure to thoroughly investigate injuries of unknown origin for three residents. Investigations lacked staff interviews, timely notifications, and proper documentation, resulting in incomplete investigations of alleged abuse or injury incidents.
Deficiencies (1)
Failure to thoroughly investigate injuries of unknown origin for three residents, including lack of staff interviews and incomplete documentation.
Report Facts
Complaint numbers investigated: 6
Total census: 139
Days bruise was old: 2
Days investigation expected: 10
Date resident R"A" admitted: Oct 30, 2021
Date resident R#2 admitted: Mar 22, 2021
Date resident R#3 admitted: May 21, 2021
Date of injury report for R#3: Sep 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Brought resident R"A" to visiting area on 11/7/2021; not the routine caregiver; not interviewed during investigation |
| BB | Activity Assistant | Took resident R"A" to day area on 11/7/2021; noticed bruise but did not know cause; not interviewed during investigation |
| CC | Certified Nursing Assistant | Assigned to resident R"A" on 11/7/2021; noticed bruise after visit; not interviewed during investigation |
| Unknown | Administrator | Received family call about resident R"A"'s injury; conducted incomplete investigation; unable to provide names of staff involved |
| Unknown | Director of Nursing | Noted bruise on resident R"A" on 11/8/2021; former DON responsible for investigation of resident R#3 |
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10-22-2020 Complaint Survey.
Complaint Details
This visit was a follow-up to a complaint survey conducted on 10-22-2020; all cited deficiencies were corrected.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 109
Deficiencies: 2
Date: Nov 10, 2020
Visit Reason
A revisit was conducted to validate removal of Immediate Jeopardy identified during an Abbreviated/Extended and COVID-19 Focused Infection Control Survey related to infection control failures and outbreak management.
Findings
The facility failed to implement an effective Infection Prevention Control Program, failed to properly cohort residents, and failed to ensure staff properly used PPE, resulting in COVID-19 spread among residents and staff, hospitalizations, and deaths. Immediate Jeopardy was removed after corrective actions including staff education, resident cohorting, leadership changes, and ongoing monitoring, but the facility remained out of compliance with systematic changes ongoing.
Deficiencies (2)
Failure to ensure an effective Infection Prevention Control Program to prevent or reduce the spread of COVID-19 to residents and staff.
Failure to ensure staff were trained to properly utilize PPE for positive and negative residents to prevent or reduce the spread of COVID-19.
Report Facts
Resident census: 109
Residents tested positive: 23
Staff tested positive: 12
Residents hospitalized: 7
Residents expired: 2
PCR COVID-19 tests completed: 83
Residents tested positive on PCR: 6
Staff in-serviced for PPE and hand hygiene: 56
Staff in-serviced for PPE and hand hygiene: 27
Staff in-serviced for PPE and hand hygiene: 19
Staff in-serviced for PPE and hand hygiene: 23
Staff in-serviced for PPE and hand hygiene: 11
Staff in-serviced for PPE and hand hygiene: 4
Registered Nurses in-serviced: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN SS | Registered Nurse | Performed rapid COVID-19 testing and described testing procedures and documentation |
| LPN TT | Licensed Practical Nurse, Unit Manager | Described resident monitoring for COVID-19 symptoms and documentation |
| ADON | Assistant Director of Nursing | Described resident monitoring, infection control observation rounds, and staff education |
| DA AAA | Dietary Aide | Described meal delivery procedures and infection control education |
| DA GGG | Dietary Aide | Described infection control education and meal delivery procedures |
| CNA XX | Certified Nursing Assistant | Described infection control education and COVID-19 symptom awareness |
| CNA EEE | Certified Nursing Assistant | Described infection control education and COVID-19 symptom awareness |
| CNA CC | Certified Nursing Assistant | Described infection control education and COVID-19 symptom awareness |
| CNA FFF | Certified Nursing Assistant | Described infection control education and COVID-19 symptom awareness |
| CNA VV | Certified Nursing Assistant | Described infection control education and COVID-19 symptom awareness |
| Housekeeper UU | Housekeeping Staff | Described infection control education and weekly COVID-19 testing |
| Housekeeper ZZ | Housekeeping Staff | Described infection control education and weekly COVID-19 testing |
| Floor Tech BBB | Maintenance Staff | Described infection control education and weekly COVID-19 testing |
| Social Services Director | Social Services Director | Described infection control education and COVID-19 symptom awareness |
| Maintenance Director | Maintenance Director | Described infection control education and staff testing procedures |
| LPN YY | Licensed Practical Nurse | Described infection control education and resident monitoring |
| LPN QQ | Licensed Practical Nurse, Unit Manager | Described infection control education and resident monitoring |
| LPN NN | Licensed Practical Nurse | Described infection control education and resident monitoring |
| LPN MM | Licensed Practical Nurse | Described infection control education and resident monitoring |
| RN CCC | Registered Nurse | Described infection control education, resident monitoring, and staff compliance |
| Activities Director | Activities Director | Described infection control education and resident/family activities |
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