Inspection Reports for
Westbury Center of McDonough for Nursing &Amp; Healing

The complaint investigation substantiated staff-to-resident sexual contact involving an Environmental Services Housekeeper and a resident with dementia. The resident was cognitively impaired but able to express preferences. The facility failed to properly investigate and protect residents, leading to immediate jeopardy. The investigation included interviews, review of camera footage, and police involvement.

The facility failed to treat a resident's verbal complaint as a grievance and did not investigate it properly. The facility also failed to protect a resident from sexual assault by an Environmental Services Housekeeper, resulting in immediate jeopardy to resident health and safety. The administration failed to provide adequate oversight and conducted a biased investigation that minimized the seriousness of the abuse.

The complaint investigation substantiated multiple environmental deficiencies and physical abuse incidents involving resident R154 abusing residents R60, R66, R73, and R200. The abuse included physical assaults causing injuries and psychosocial harm. The facility failed to prevent and adequately respond to these incidents.

The facility failed to maintain a clean and homelike environment, with multiple observations of unclean rooms, soiled floors, broken fixtures, and cluttered shower rooms. Additionally, the facility failed to protect residents from physical abuse by another resident, resulting in actual harm and psychosocial harm to several residents.

The complaint investigation substantiated that the facility failed to maintain a safe and homelike environment and failed to protect residents from physical abuse. Four residents were physically abused by another resident, resulting in injuries and psychosocial harm. The facility was aware of the incidents and took some actions including psychiatric evaluation and discharge planning for the abusive resident.

The facility failed to maintain a clean and homelike environment, with multiple observations of soiled floors, broken fixtures, cluttered shower rooms, and maintenance issues. Additionally, the facility failed to protect several residents from physical abuse by another resident, resulting in actual harm and psychosocial harm.

The facility failed to provide quarterly resident trust fund statements to all residents with accounts, administered oxygen therapy at incorrect flow rates for one resident, and did not maintain consistent communication with the dialysis center for three residents receiving dialysis.

The complaint was substantiated. The investigation confirmed the oxygen flow rate was set higher than ordered for resident R1, with staff interviews verifying the error and potential cause.

The facility failed to ensure oxygen was administered at the prescribed rate of 2 liters per minute via nasal cannula for resident R1, who was observed receiving oxygen at 4 liters per minute. Staff interviews confirmed the oxygen flow was incorrectly set, potentially causing respiratory distress.

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.

Complaint Intake Numbers GA00239501, GA00238090, GA00237937, GA00236260, GA02361690, GA00236131, GA00236128, and GA00236133 were investigated and found to be unsubstantiated.

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.

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.

The complaint investigation was triggered by multiple resident, family, and staff concerns regarding resident neglect, inadequate care, medication errors, staffing shortages, infection control breaches, and failure to follow regulatory requirements for notifications and discharge planning.

The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, inadequate notification of Medicare coverage and discharge notices, unsafe and unsanitary environmental conditions, neglect in resident care including bathing and incontinent care, insufficient staffing levels, medication administration errors, inadequate social services and discharge planning, and failure to maintain infection prevention and control standards.

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.

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.

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.

The complaint investigation was initiated due to multiple resident and family concerns about neglect, inadequate care, medication errors, infection control breaches, and failure to follow regulatory requirements for discharge and notification.

The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, failure to provide required Medicare notices, unsafe and unsanitary environment conditions, neglect of residents including inadequate incontinent care and showering, failure to notify Ombudsman of transfers and discharges, lack of individualized discharge care plans, failure to provide scheduled activities of daily living, insufficient staffing levels, medication administration errors, and inadequate infection prevention and control practices.

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.

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.

Multiple complaint intake numbers were investigated in conjunction with the standard survey. Five complaints were substantiated without deficiencies and one was unsubstantiated.

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.

The complaint investigation focused on failure to notify the physician and responsible party timely after a resident's fall and self-injurious behavior, failure to send the resident to the emergency room promptly, failure to implement restorative nursing services, unsanitary ice machine conditions, and lack of antibiotic stewardship monitoring. The investigation substantiated actual harm to residents and multiple regulatory deficiencies.

The facility failed to promptly notify the physician and responsible party after a resident's fall resulting in a head laceration requiring staples, neglected to send the resident to the emergency room for 37 hours, failed to implement restorative nursing services as ordered, failed to maintain sanitary conditions of an ice machine, and lacked evidence of an antibiotic stewardship monitoring program for nine months.