Inspection Reports for Westbury Center of McDonough for Nursing &Amp; Healing
198 HAMPTON STREET, MCDONOUGH, GA, 30253
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 23, 2025, found no deficiencies and the complaint investigated was unsubstantiated. Earlier inspections showed a pattern of deficiencies related mainly to resident trust fund statement reporting, oxygen administration, communication with dialysis centers, infection control, resident dignity and care, staffing levels, and environmental safety issues. Prior complaint investigations were mostly unsubstantiated, though a substantiated complaint in early 2022 identified failures in timely physician notification after a resident fall, care plan implementation, and employee health screenings. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections indicating correction of previously cited deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
146 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 146
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00242147.
Complaint Details
Complaint GA00242147 was investigated and found to be unsubstantiated.
Findings
The complaint GA00242147 was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westbury Center of McDonough for Nursing & Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 144
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 12/21/2023 recertification and complaint survey.
Findings
All deficiencies cited in the prior 12/21/2023 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies have been corrected.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
A State Licensure survey was conducted at Westbury Center of McDonough for Nursing and Healing from December 19, 2023, through December 21, 2023, to assess compliance with state health regulations.
Findings
The facility failed to provide quarterly resident trust fund statements to all 82 residents with accounts, instead providing monthly billing statements. Interviews confirmed residents were unaware of their account balances and the facility had not sent quarterly statements since March 2023.
Deficiencies (1)
Failure to provide quarterly resident trust fund statements to 82 of 82 residents with accounts.
Report Facts
Residents without quarterly statements: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding provision of monthly billing statements instead of quarterly trust fund statements. |
| Administrator | Administrator | Interviewed and revealed facility had not sent quarterly resident trust fund statements since March 2023. |
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 3
Date: Dec 21, 2023
Visit Reason
A Standard survey was conducted from December 19 through December 21, 2023, by the Georgia Department of Community Health, including investigation of multiple complaint intake numbers which were found to be unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00239501, GA00238090, GA00237937, GA00236260, GA02361690, GA00236131, GA00236128, and GA00236133 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide quarterly resident trust fund statements to residents, improper oxygen administration rate for one resident, and failure to maintain consistent communication with the dialysis center for three residents receiving dialysis.
Deficiencies (3)
Facility failed to provide quarterly resident trust fund statements to 82 of 82 residents with accounts.
Facility failed to ensure oxygen administered by nasal cannula was set at the prescribed rate for one resident, potentially causing respiratory distress.
Facility failed to maintain consistent communication with the dialysis center for three residents receiving dialysis, including failure to review communication forms and notify the dialysis center when forms were incomplete.
Report Facts
Resident census: 144
Residents with resident trust fund accounts: 82
Residents receiving oxygen therapy: 25
Residents receiving dialysis: 8
Dialysis Communication Records missing documentation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Verified oxygen order and observed oxygen flow rate discrepancy for resident R1 |
| DD | Unit Manager | Confirmed oxygen order and excess oxygen flow for resident R1 |
| Director of Nursing (DON) | Director of Nursing | Provided information on respiratory therapist availability and dialysis communication expectations |
| AA | Licensed Practical Nurse (LPN) | Discussed dialysis communication form issues and frequency changes for resident R109 |
| BB | Licensed Practical Nurse (LPN) | Discussed dialysis communication form process |
| Regional Nurse | Regional Nurse | Reported audit findings of incomplete dialysis communication records |
| Business Office Manager (BOM) | Business Office Manager | Provided information on billing statements versus quarterly trust fund statements |
| Administrator | Administrator | Confirmed quarterly resident trust fund statements had not been sent since March 2023 |
Inspection Report
Life Safety
Census: 145
Capacity: 210
Deficiencies: 14
Date: Dec 19, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including blocked exits, improper locking devices on egress doors, malfunctioning exit signage, fire alarm system deficiencies, sprinkler system maintenance issues, blocked fire extinguishers, smoking regulation violations, oversized soiled linen containers, fire door maintenance failures, improper use of extension cords, and unsecured oxygen cylinders.
Deficiencies (14)
Exit leading out of the kitchen was blocked and obstructed.
Kitchen egress doors had more than one locking device.
Smoke detectors installed more than five feet from doors held open by mag locks.
Corridors were blocked on Westbury Hall.
Exit sign not working properly on Heritage Hall by Door #4.
Facility failed to identify, lock out, and mark FACP breaker in red.
Smoke detector #70 was hanging from the ceiling and not properly installed.
Sprinkler escutcheon rings not adjusted or installed properly in Heritage Hall and maintenance shop.
Fire extinguisher blocked by dining room door that remains open.
Facility failed to maintain a smoke-free environment; cigarette butts found outside with no ashtrays or metal cans.
Soiled linen containers larger than 32 gallons (two 55 gallon containers) and soiled linen closet door would not close completely.
Fire door on McDonough Hall did not close properly.
Extension cords used as permanent wiring in dining facilities manager's office.
Oxygen cylinders were not properly secured within closet.
Report Facts
Census: 145
Total Capacity: 210
Soiled linen container size: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 12/19/2023 |
Inspection Report
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the Westbury Center of McDonough for Nursing & Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 131
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
A revisit was conducted at Westbury Center of McDonough starting 7/17/23 and concluded on 7/20/23 to verify correction of deficiencies cited as a result of an extended complaint survey.
Complaint Details
The revisit was conducted following an extended complaint survey; deficiencies cited in that complaint survey were corrected.
Findings
All deficiencies cited during the extended complaint survey were found to be corrected as of 6/19/23.
Report Facts
Facility census: 131
Inspection Report
Routine
Census: 141
Deficiencies: 9
Date: May 5, 2023
Visit Reason
A State Licensure survey was conducted at Westbury Center of Nursing and Health from March 17, 2023 through May 5, 2023 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to provide required Medicare beneficiary notices, inadequate promotion of resident dignity and personal choice, failure to notify Ombudsman of transfers and discharges, lack of individualized discharge care plans, insufficient nursing staff, failure to provide adequate social services and referrals, infection control lapses, inadequate activities of daily living care, and environmental sanitation issues including dirty air filters and vents.
Deficiencies (9)
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to residents discharged from Medicare Part A services.
Failure to promote care maintaining resident dignity, respect, and individuality, including staff entering rooms without knocking and pulling residents backward in chairs.
Failure to notify Ombudsman about resident transfers and discharges, including discharges against medical advice.
Failure to develop individualized discharge care plans for residents discharged from the facility.
Insufficient nursing staff on multiple halls and departments, resulting in inadequate resident care and unmet needs.
Failure to provide timely social services and referrals for resident transfer, specifically for one resident.
Failure to follow infection control procedures including improper cleaning of glucometers, improper PPE use, and lack of hand sanitizer availability.
Failure to provide scheduled activities of daily living care including bathing, oral care, and shaving for dependent residents.
Failure to maintain a safe, clean, and comfortable environment including dirty air filters and vents on PTAC units, missing ceiling tiles, and dirty exhaust fans.
Report Facts
New admissions: 21
Census: 141
Certified Nursing Assistants scheduled: 7
Certified Nursing Assistants scheduled: 6
Residents per CNA: 20
Residents per CNA: 24
Residents sampled: 46
Residents with dignity issues: 9
Residents with ADL care issues: 3
Resident rooms inspected: 31
Hand sanitizer dispensers not working: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nurse's Aide | Named in dignity and respect deficiency for pulling residents backward in chairs |
| Social Service Director (SSD) | Responsible for providing beneficiary notices and discharge notifications | |
| Administrator | Responsible for ensuring beneficiary notices and addressing staffing issues | |
| Director of Nursing (DON) | Named in dignity and respect deficiency and staffing issues | |
| CMA JJ | Certified Medication Aide | Failed to clean glucometer between resident use |
| LPN LL | Licensed Practical Nurse | Improper glucometer placement and infection control |
| Laundry Aide SS | Placed washcloth fallen on floor with clean linen | |
| Account Manager MM | Aware of hand sanitizer dispenser issues and laundry incident | |
| Maintenance Director (MD) | Responsible for PTAC unit maintenance and cleaning |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 11
Date: May 5, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint numbers, initiated on March 17, 2023 and concluded on May 5, 2023.
Complaint Details
The complaint investigation included multiple complaint numbers related to infection control and resident care issues. The facility was found not in compliance with infection control regulations and had multiple deficiencies as detailed in the findings.
Findings
The facility was found not in compliance with infection control regulations and had multiple deficiencies including failure to maintain resident dignity and respect, failure to provide required notices for Medicare Part A discharges, inadequate environmental maintenance, neglect of residents, failure to notify Ombudsman of discharges, lack of discharge care plans, failure to provide scheduled activities of daily living including showers and oral care, insufficient staffing, medication errors, and infection control breaches including improper cleaning of glucometers and lack of hand sanitizer availability.
Deficiencies (11)
Failure to promote care in a manner that maintained or enhanced each resident's dignity, respect, and individuality for nine of 46 sampled residents.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage for three of five residents discharged from Medicare Part A services.
Failure to maintain a safe, clean, and comfortable environment with dirty air filters and vents on PTAC units, missing ceiling tiles, and dirty exhaust fans in resident bathrooms.
Failure to ensure three of six residents were free from neglect related to delayed assistance after falls, prolonged bed confinement due to lack of staff, and failure to provide incontinent care.
Failure to notify Ombudsman about four of seven residents reviewed for discharge or transfer.
Failure to develop discharge care plans for five of seven residents reviewed for discharge.
Failure to provide scheduled showers and oral care for nine of 46 sampled residents.
Failure to provide scheduled showers, oral care, and shaving for three of 46 sampled residents.
Failure to provide sufficient staff on three of four halls, receptionist area, and environmental services to achieve highest practicable level of well-being for all residents.
Failure to prevent medication errors resulting in decline in condition for one resident and failure to administer medications as ordered for another resident.
Failure to follow infection control procedures for cleaning and disinfecting glucometers, improper use of PPE, mixing clean and soiled linen, lack of hand sanitizer at stations, and lack of soap and paper towels in resident rooms.
Report Facts
Resident census: 143
New admissions: 21
CNA staffing: 6
CNA staffing: 7
Residents per CNA: 20
Residents per CNA: 24
Medication errors: 1
Medication errors: 1
Hand sanitizer dispensers not working: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nurse's Aide | Named in findings related to improper resident transport and failure to knock before entering rooms |
| Director of Nursing | Director of Nursing | Named in interview regarding staff expectations for resident dignity and respect |
| Social Service Director | Social Service Director | Named in interview regarding failure to provide beneficiary notices and discharge referrals |
| Administrator | Administrator | Named in interview regarding responsibility for beneficiary notices and staffing issues |
| Maintenance Director | Maintenance Director | Named in interview regarding facility maintenance deficiencies |
| CNA VV | Certified Nursing Assistant | Named in interview regarding oral care assistance |
| CMA GG | Certified Medication Aide | Named in medication error observation and interview |
| LPN LL | Licensed Practical Nurse | Named in medication error observation and interview |
| Account Manager MM | Account Manager | Named in interview regarding hand sanitizer dispenser issues and laundry incident |
| District Manager | District Manager | Named in interview regarding environmental services staffing and cleaning issues |
| Regional Vice President of Operations | Regional Vice President of Operations | Named in interview regarding environmental services staffing and cleaning issues |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00228234 from 09/27/2022 to 09/29/2022.
Complaint Details
Complaint #GA00228234 was investigated and substantiated with no deficiencies.
Findings
The complaint was substantiated with no deficiencies found during the investigation.
Inspection Report
Deficiencies: 0
Date: May 19, 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 detailed findings or deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 12, 2022
Visit Reason
A revisit survey was conducted from 5/10/22 through 5/12/22 to verify correction of deficiencies cited in the 2/20/22 through 2/23/22 Standard Survey and to investigate multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00221998, GA00222570, GA00223214, GA00222699, and GA00221799 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior standard survey were found to be corrected. The complaint investigations were found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 15, 2022
Visit Reason
The inspection was conducted as a licensure survey initially from February 20-23, 2022, reopened for additional information and interviews, and concluded on March 15, 2022. The visit was triggered by complaints related to failure to promptly notify physicians and responsible parties of resident changes, failure to implement care plans, and employee health and background screening deficiencies.
Complaint Details
The complaint investigation revealed substantiated issues including delayed notification to the physician and responsible party after a resident fall with injury, failure to implement care plans, and incomplete employee health and background screening documentation.
Findings
The facility failed to promptly notify the physician and responsible party of a resident's fall and subsequent head injury, resulting in actual harm. The facility also failed to implement person-centered care plans for residents, including restorative nursing services. Additionally, the facility did not ensure employees received required physical exams, tuberculosis screenings, or background checks prior to employment. Documentation and record-keeping issues were identified amid leadership turnover.
Deficiencies (4)
Failure to promptly notify the Physician and responsible party timely for a change in condition including a fall and self-injurious behavior after a fall for resident #119.
Failure to implement the person-centered care plan related to notifying the Physician after a fall for resident #119 and failure to follow care plan for active range of motion for resident #24.
Failure to ensure employees received annual physical examinations or screenings for communicable diseases prior to employment for multiple employees.
Failure to obtain State Survey Agency approved criminal background checks and reference checks for employees prior to employment.
Report Facts
Date of resident fall: Feb 19, 2022
Staples required: 10
Sample size: 38
Employee files reviewed: 10
Employees missing physical exam: 4
Employees missing TB screening: 7
Employees missing background check: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Nurse on duty during resident #119 fall; did not notify physician immediately |
| LPN DD | Licensed Practical Nurse | Observed resident hitting head; did not notify physician |
| LPN AA | Licensed Practical Nurse | Changed resident #119 bandage; did not report head injury immediately |
| Physician GG | Physician | Expected immediate notification for resident self-harm behavior |
| Unit Manager EE | Unit Manager | Notified physician of resident fall on 2/20/2022 at 4:25 p.m. |
| Director of Nursing | Director of Nursing (DON) | Unaware of resident fall and head injury initially; expected immediate notification |
| Administrator | Facility Administrator | Confirmed incomplete employee files and ongoing investigation |
| Vice President of Operations | Vice President of Operations | Reported leadership turnover and ongoing review of facility processes |
Inspection Report
Routine
Census: 133
Deficiencies: 6
Date: Mar 15, 2022
Visit Reason
A standard survey was conducted from February 20, 2022 through February 23, 2022, including investigation of multiple complaint intake numbers. The survey was reopened to obtain additional information and concluded on March 15, 2022.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Five complaints were substantiated without deficiencies and one was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with actual harm identified due to a resident fall resulting in a head laceration requiring staples. Deficiencies included failure to promptly notify the physician of changes in condition, failure to provide timely treatment, failure to implement person-centered care plans, unsanitary conditions of an ice machine, failure to provide restorative nursing services as ordered, and lack of an antibiotic stewardship monitoring system.
Deficiencies (6)
Failure to promptly notify the physician and responsible party of a resident's fall and change in condition, resulting in actual harm.
Failure to ensure resident was free from neglect by not sending resident to the hospital for head injury for 37 hours after fall.
Failure to implement person-centered care plan related to notifying physician after a fall and failure to follow care plan for active range of motion for a resident.
Failure to maintain sanitary condition of an ice machine with rust-colored substance and dust buildup.
Failure to provide restorative nursing services as ordered for one resident, with missing documentation for several months.
Failure to provide evidence of a monitoring system to track and trend antibiotic use for nine months.
Report Facts
Resident census: 133
Staples required: 10
Hours delay: 37
Restorative nursing frequency: 3
Restorative nursing documentation gap: 6
Ice machine cleaning frequency: 3
Antibiotic stewardship monitoring gap: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Nurse on duty when resident #119 fell, did not notify physician due to time of night |
| LPN DD | Licensed Practical Nurse | Observed resident hitting head, did not notify physician |
| LPN AA | Licensed Practical Nurse | Changed dressing on resident #119's head but did not notify anyone |
| Physician HH | Physician | Notified late about resident #119's fall and head injury |
| DON | Director of Nursing | Unaware of resident #119's fall and head injury until late; expected immediate notification |
| CDM | Certified Dietary Manager | Reported ice machine was dirty but kitchen staff did not notify maintenance |
| Maintenance Director | Maintenance Director | Responsible for cleaning ice machine every three months; no cleaning logs maintained |
| ICP | Infection Control Preventionist | Employed since October 2021; no antibiotic stewardship documentation prior to employment |
| Regional Nurse Consultant | Regional Registered Nurse Consultant | Confirmed no additional antibiotic stewardship documentation available |
| Administrator | Facility Administrator | Confirmed lack of restorative nursing documentation and expected sanitary maintenance of equipment |
Inspection Report
Life Safety
Census: 131
Capacity: 210
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
A Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found to be in compliance with the requirements set forth in 42 CFR 483.90(a) and the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Abbreviated Survey
Census: 118
Deficiencies: 0
Date: Aug 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints at Westbury Center of McDonough for Nursing & Healing from August 24 through August 26, 2021.
Complaint Details
Complaints #GA00214009, #GA00214459, #GA00215094, and #GA00216444 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints investigated were unsubstantiated with no regulatory violations cited. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Facility census: 118
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