Inspection Reports for Westbury Center of Jackson for Nursing and Healing
922 MCDONOUGH ROAD, JACKSON, GA, 30233
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 3, 2025, found no deficiencies, and a complaint investigation was unsubstantiated. Earlier inspections showed a pattern of deficiencies related to resident dignity and privacy during care, medication management including improper self-administration and insulin errors, restorative nursing care, and environmental maintenance issues such as unclean HVAC filters and room repairs. A substantiated complaint from July 2024 involved psychosocial harm due to staff racial comments and failure to notify family of resident condition changes, resulting in termination of two CNAs. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies effectively, with multiple revisit surveys confirming corrections and recent inspections showing improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
181 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Westbury Center of Jackson 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: Apr 3, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the February 2, 2025 recertification survey and to investigate Complaint Intake Number GA00254000.
Complaint Details
Complaint Intake Number GA00254000 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the February 2, 2025 recertification survey and to investigate Complaint Intake Number GA00254000.
Complaint Details
Complaint Intake Number GA00254000 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The follow-up survey noted that all previously cited tags have been corrected.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 6, 2025
Visit Reason
A State Licensure survey was conducted at Westbury Center of Jackson for Nursing and Healing from February 4, 2025, through February 6, 2025, to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to maintain resident dignity and privacy during care, improper medication storage without assessment for self-administration, lack of restorative nursing care for range of motion and mobility, and environmental sanitation issues such as dirty and torn PTAC filters and chipped paint with loose baseboards in resident rooms.
Deficiencies (4)
Failure to provide care in a manner that maintained or enhanced a resident's dignity and privacy during ADL care with door open and privacy curtain not fully drawn.
Medications were left at the bedside of two residents who were not assessed or authorized for medication self-administration, posing risk of misuse or overdose.
Restorative nursing care was not provided to a resident requiring range of motion and splint use, risking worsening contractures and diminished quality of life.
PTAC filters in two resident rooms were dirty or torn, and two resident bathrooms had chipped paint and loose baseboards, risking unsanitary and unsafe living conditions.
Report Facts
Number of sampled residents: 53
Number of residents with medication storage deficiency: 2
Number of residents sampled for restorative care: 2
Number of resident rooms with PTAC filter issues: 2
Number of resident rooms with environmental damage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Certified Nurse Assistant | Provided resident care with door open, not fully following privacy protocol |
| HH | Licensed Practical Nurse | Confirmed door should be closed and privacy curtain fully drawn during care |
| AA | Certified Nursing Assistant | Unaware of medication left at resident bedside |
| BB | Licensed Practical Nurse | Stated no residents approved for self-administration of medication |
| MM | Licensed Practical Nurse | Stated residents must have physician's order and assessment for medication self-administration |
| OO | Unit Manager/LPN | Confirmed assessment and physician's order required for medication self-administration |
| II | Certified Nursing Assistant | Unaware that resident R99 needed a splint |
| JJ | Certified Nursing Assistant | Unaware that resident R99 needed or used a splint |
| Director of Nursing | Director of Nursing | Provided expectations for privacy during care and medication self-administration policies |
| Director of Rehabilitation | Director of Rehabilitation | Explained splint use for resident R99 and responsibility of CNAs to apply splint |
| Maintenance Director | Maintenance Director | Confirmed PTAC filters were dirty or torn and needed cleaning or replacement |
| Administrator | Administrator | Stated residents must be capable of self-administering medication and air filters should be cleaned monthly |
Inspection Report
Routine
Census: 181
Deficiencies: 6
Date: Feb 6, 2025
Visit Reason
A Standard survey was conducted from February 4 through February 6, 2025, including investigation of complaint intake numbers GA00248772, GA00253000, and GA00253349.
Complaint Details
Complaint Intake Numbers GA00248772, GA00253000, and GA00253349 were investigated in conjunction with the Standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain resident dignity and privacy, improper medication self-administration practices, unclean HVAC filters, maintenance issues in resident rooms, failure to submit PASARR Level II applications for certain residents, failure to provide restorative nursing care as ordered, and medication administration errors with insulin pens.
Deficiencies (6)
Failure to provide care maintaining resident dignity and privacy during ADL care with door open and privacy curtain not fully drawn.
Failure to ensure medications were not left at bedside of residents not assessed for self-administration, risking misuse or overdose.
Failure to maintain PTAC filters in clean condition and maintain home-like environment due to chipped paint and loose baseboards in resident rooms.
Failure to submit Level II PASARR applications for three residents with qualifying diagnoses.
Failure to provide restorative nursing care including application of splint for resident with contracture as ordered by therapy.
Medication error rate exceeded 5% due to insulin pen injections not held in place for required time, risking incomplete dosing.
Report Facts
Residents sampled: 53
Residents with medication errors: 2
Medication error rate: 6.67
Residents with PASARR Level II missing: 3
Facility census: 181
BIMS score: 7
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA GG | Certified Nurse Assistant | Named in privacy deficiency for providing care with door open |
| LPN HH | Licensed Practical Nurse | Confirmed door should be closed during care for privacy |
| Director of Nursing | Director of Nursing | Stated expectation for privacy and medication self-administration assessment |
| CNA AA | Certified Nursing Assistant | Unaware of medication left at bedside for resident R86 |
| LPN BB | Licensed Practical Nurse | Stated no residents approved for self-administration and protocol for medication found at bedside |
| LPN MM | Licensed Practical Nurse | Uncertain about nasal spray presence in resident R287's room |
| Unit Manager/LPN OO | Unit Manager/Licensed Practical Nurse | Confirmed no assessment or order for medication self-administration for resident R287 |
| Maintenance Director | Maintenance Director | Confirmed dirty and torn PTAC filters and maintenance issues in resident rooms |
| Social Services Director | Social Services Director | Unaware of responsibility for PASARR Level II submissions |
| Director of Rehabilitation | Director of Rehabilitation | Confirmed resident R99 required splint and CNAs responsible for applying it |
| CNA II | Certified Nursing Assistant | Unaware of resident R99's splint needs |
| CNA JJ | Certified Nursing Assistant | Unaware of resident R99's splint needs |
| CMA PP | Certified Medical Assistant | Observed medication administration errors with insulin pens |
| Staff Educator | Staff Educator | Stated expectation for insulin pen injection technique |
Inspection Report
Life Safety
Census: 172
Capacity: 179
Deficiencies: 2
Date: Feb 4, 2025
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to multiple exit doors at the 100 Hall and 200 Hall failing to close and latch properly, potentially allowing smoke migration into two of five smoke compartments affecting 60 residents. Additionally, corridor openings did not meet NFPA 101 standards regarding transfer grilles and louvers.
Deficiencies (2)
Transfer grilles are not used in corridor walls or doors; auxiliary spaces without flammable materials have louvers or are undercut, which is not compliant.
Multiple exit doors at the 100 Hall and 200 Hall do not close and latch properly, risking smoke migration into smoke compartments.
Report Facts
Census: 172
Total Capacity: 179
Number of smoke compartments affected: 2
Number of residents potentially affected: 60
Number of exit doors not closing properly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings of exit doors not closing and latching properly |
Inspection Report
Re-Inspection
Census: 178
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on July 12, 2024.
Complaint Details
The revisit survey followed a complaint survey conducted on July 12, 2024; all prior deficiencies were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected during the revisit survey.
Report Facts
Census: 178
Inspection Report
Complaint Investigation
Census: 177
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
A complaint survey was conducted from July 8, 2024 through July 12, 2024 to investigate multiple complaint intake numbers regarding alleged abuse and failure to notify family of changes in resident condition.
Complaint Details
Complaint Intake Numbers GA00241587 and GA00244449 were substantiated with deficiencies related to abuse and failure to notify family. Psychosocial harm was identified when a CNA made racial comments causing a resident to become distraught and leave the facility. The facility failed to notify a resident's family of changes in condition despite refusals of care and acute symptoms. The abuse investigation included interviews, video review, and police involvement, resulting in termination of two CNAs.
Findings
The survey found the facility was not in substantial compliance with Medicare/Medicaid regulations, substantiating psychosocial harm due to racial comments by a CNA causing a resident to leave the facility. Additionally, the facility failed to notify a resident's family of changes in condition and failed to protect a resident from verbal and physical abuse by staff. Two CNAs were terminated following the substantiated abuse.
Deficiencies (2)
Failed to notify the resident's representative of a change in the resident's condition for 1 of 3 sampled residents.
Failed to protect the resident's right to be free from verbal and physical abuse by staff, including racial comments and physical force causing psychosocial harm.
Report Facts
Complaint Intake Numbers Investigated: 5
Residents Present: 177
Brief Interview for Mental Status (BIMS) score: 13
Brief Interview for Mental Status (BIMS) score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Named in verbal and physical abuse findings, terminated after investigation |
| CNA 6 | Certified Nursing Assistant | Named in verbal and physical abuse findings, terminated after investigation |
| Director of Nursing | Director of Nursing | Interviewed regarding notification failures and responsible party expectations |
| RN Supervisor | Registered Nurse Supervisor | Involved in investigation and communication with resident's responsible party |
| Administrator | Facility Administrator | Provided details on incident and staff behavior during abuse investigation |
| Nurse Practitioner 2 | Nurse Practitioner | Provided clinical background on resident R1 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westbury Center of Jackson for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The document does not provide specific findings or deficiencies; it serves as a cover sheet for the Statement of Deficiencies and Plan of Correction.
Inspection Report
Re-Inspection
Census: 181
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 31, 2023, Recertification survey and Complaint Investigation survey.
Findings
All deficiencies cited in the prior August 31, 2023 surveys were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 177
Capacity: 198
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the requirements set forth in 42 CFR 483.73 and 42 CFR Subpart 483.90(a), Life Safety from Fire, as well as the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Routine
Deficiencies: 3
Date: Aug 31, 2023
Visit Reason
A State Licensure survey was conducted at Westbury Center of Jackson from August 29, 2023 through August 31, 2023 to assess compliance with state health regulations.
Findings
The facility failed to maintain infection control standards by not timely removing an intravenous (IV) access after discontinuation of IV antibiotic for one resident, not keeping nebulizer masks enclosed in bags when not in use, and not cleaning or disinfecting equipment between residents who were COVID-19 positive. Multiple staff interviews confirmed lack of adherence to policies and procedures regarding respiratory equipment storage and equipment sanitization.
Deficiencies (3)
Failure to remove intravenous (IV) access timely after discontinuation of IV antibiotic for Resident #8.
Nebulizer mask not kept enclosed inside a zip lock bag when not in use for Resident #39.
Failure to clean or disinfect vital sign monitoring equipment between residents who were COVID-19 positive in room 508.
Report Facts
IV fluid rate: 50
IV fluid duration: 3
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Certified Nursing Assistant (CNA) | Interviewed regarding respiratory equipment storage and education |
| JJ | Registered Respiratory Therapist (RRT) | Interviewed regarding respiratory equipment storage and education |
| NN | Certified Medication Assistant (CMA) | Interviewed regarding respiratory equipment handling |
| KK | Licensed Practical Nurse (LPN) | Interviewed regarding respiratory equipment storage and education |
| LL | Certified Nursing Assistant (CNA) | Observed and interviewed regarding sanitization of vital sign equipment and use of PPE |
| OO | Certified Nursing Assistant (CNA) | Interviewed regarding cleaning multi-use resident equipment |
| HH | Registered Nurse (RN) / Community Manager | Interviewed regarding IV status and discontinuation for Resident #8 |
| II | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and IV flushing for Resident #8 |
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding IV orders and discontinuation procedures |
| Regional Director of Clinical Operations | Interviewed regarding expectations for staff compliance with policies and procedures | |
| RN/ Regional Nurse Consultant | Interviewed regarding expectation that IV be removed at completion of therapy |
Inspection Report
Annual Inspection
Census: 186
Deficiencies: 3
Date: Aug 31, 2023
Visit Reason
A recertification survey was conducted from 8/29/2023 to 8/31/2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Westbury Center of Jackson for Nursing and Healing.
Complaint Details
Complaint Intake Numbers GA00237932, GA00232138, and GA00228168 were unsubstantiated. Complaint Intake Number GA00237344 was substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to complete and submit a discharge MDS assessment, improper insulin pen administration without priming, failure to maintain infection control standards including timely removal of IV access, improper storage and cleaning of respiratory and shared equipment, and inadequate staff education and adherence to policies.
Deficiencies (3)
Failure to ensure Comprehensive Minimum Data Set (MDS) discharge assessments were completed and submitted for one resident.
Licensed Practical Nurse administered insulin without priming the insulin pen needle prior to administration.
Failure to maintain infection control standards by not timely removing intravenous (IV) access after discontinuation, improper storage of nebulizer mask, and failure to clean/disinfect equipment between residents with COVID-19.
Report Facts
Resident census: 186
Residents reviewed for MDS discharge: 55
Insulin dose: 8
IV fluid rate: 50
IV fluid duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering insulin without priming the insulin pen needle |
| MDS Coordinator BB | MDS Coordinator | Confirmed MDS discharge assessment omission for Resident #B |
| RN / Community Manager HH | Registered Nurse / Community Manager | Verified IV status and care for Resident #8 |
| LPN II | Licensed Practical Nurse | Unaware of Resident #8's IV and did not flush it |
| LPN CC | Licensed Practical Nurse | Explained IV orders and discontinuation procedures |
| CNA LL | Certified Nursing Assistant | Observed failing to sanitize vital sign machine between residents on Transmission Based Precautions |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 23, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN) during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 05/15/2023 and 05/21/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Re-Inspection
Census: 182
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the complaint survey conducted on 2022-08-11.
Complaint Details
The revisit survey was conducted following a complaint survey on 2022-08-11. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 8/11/2022 complaint survey were found to be corrected during the revisit survey.
Report Facts
Census: 182
Inspection Report
Abbreviated Survey
Census: 178
Deficiencies: 2
Date: Aug 11, 2022
Visit Reason
An Abbreviated Survey was conducted from July 6, 2022 to August 11, 2022, investigating multiple complaints and a Focused Infection Control survey.
Complaint Details
Complaint GA00221093 and GA00223324 were substantiated with deficiencies. Complaint GA00225587 was substantiated without deficiencies. Complaints GA00221105, GA00221224, GA00223433, GA00225211, and GA00226250 were unsubstantiated.
Findings
The facility was found in compliance with COVID-19 emergency preparedness and infection control regulations. However, deficiencies were substantiated related to failure to post nurse staffing information on multiple days and failure to assist a resident promptly in obtaining dental care after losing dentures.
Deficiencies (2)
Failure to post up-to-date nurse staffing information on 7/13/2022, 7/14/2022, 7/15/2022, and 7/20/2022.
Failure to assist resident #12 in obtaining dental care promptly after losing upper dentures, resulting in weight loss and lack of communication with family.
Report Facts
Resident census: 178
Weight loss: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant | Confirmed resident #12 has upper and lower dentures and described denture care. |
| BB | Housekeeper | Assisted resident #12 with room change and was informed of missing dentures but did not report it. |
Inspection Report
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Westbury Center of Jackson for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 161
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/20/22 Recertification Survey.
Findings
All deficiencies cited during the 1/20/22 Recertification Survey were found to be corrected.
Inspection Report
Original Licensing
Deficiencies: 1
Date: Jan 20, 2022
Visit Reason
A Licensure Survey was conducted from 1/18/22 through 1/20/22 to assess compliance with nursing care requirements and licensure standards at the facility.
Findings
The facility failed to provide scheduled showers for two residents who were dependent on staff for activities of daily living, resulting in deficiencies related to nursing care and documentation of ADL completion.
Deficiencies (1)
The facility failed to provide scheduled showers for two residents (#11 and #140) dependent on staff for activities of daily living.
Report Facts
Sample size: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Registered Nurse (RN) | Stated expectations for CNA staff to provide ADL care and follow bath schedule |
| BB | Certified Nursing Assistant (CNA) | Described determining shower assignments and level of care needs |
| Director of Nursing (DON) | Director of Nursing | Monitors ADL care completion and discussed concerns in QAPI meetings |
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 1
Date: Jan 20, 2022
Visit Reason
A standard survey was conducted from January 18, 2022 through January 20, 2022, including investigation of Complaint Intake Number GA00220455, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00220455 was investigated in conjunction with the standard survey. The complaint involved failure to provide scheduled showers to residents, which was substantiated by observations, interviews, and record review.
Findings
The facility failed to provide scheduled showers for two dependent residents (#11 and #140), despite documented care plans and resident requests. Interviews and record reviews revealed inconsistent shower provision and inadequate documentation of ADL care.
Deficiencies (1)
Failure to provide scheduled showers for two dependent residents requiring assistance with activities of daily living.
Report Facts
Resident census: 153
Sample size: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Registered Nurse (RN) | Stated expectation for CNA staff to provide ADL care related to showers and follow bath logbook |
| BB | Certified Nursing Assistant (CNA) | Determines shower assignments and level of care needs based on Kardex and shower book |
| Director of Nursing (DON) | Director of Nursing | Monitors completion of ADL care, reviews progress notes, and discusses concerns in QAPI meetings |
Inspection Report
Life Safety
Census: 148
Capacity: 196
Deficiencies: 0
Date: Jan 19, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare/Medicaid under 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition. However, 27 patient rooms in hallways 700 and 800 were not surveyed due to occupancy by COVID patients.
Report Facts
Patient rooms not surveyed: 27
Inspection Report
Abbreviated Survey
Census: 142
Deficiencies: 0
Date: Oct 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and assess compliance with infection control regulations.
Complaint Details
Complaint #GA00216613 was substantiated with no regulatory violations cited. Complaints #GA00217804, #GA00217504, and #GA00216007 were unsubstantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended COVID-19 practices. One complaint was substantiated with no regulatory violations cited; other complaints were unsubstantiated with no violations.
Report Facts
Complaints investigated: 4
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