Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westbury Center Of Conyers For Nursing And Healing during CMS and state inspections, most recent first.
A resident with bowel and bladder incontinence, UTI, muscle weakness, and moderately impaired cognition required staff assistance for toileting hygiene and perineal care. During observed incontinence care, a CNA changed gloves without performing required hand hygiene between glove removal and donning new gloves, contrary to the facility’s infection prevention and control and hand hygiene policies. In interviews, the CNA, SDC, and DON all confirmed that hand washing or sanitizing is expected between glove changes and that not doing so can lead to spread of germs, cross-contamination, or infection.
A resident with upper extremity impairment and total dependence for care was not provided with a call device she could use, despite staff awareness of her inability to activate the standard call light. The care plan did not address her needs, and no appropriate assessment or device was provided, leaving her unable to independently request assistance.
A resident who was not cognitively intact was transferred to a hospital on two occasions without being provided a written bed hold notice or reason for transfer, as required by facility policy. The resident's representative confirmed not receiving the notice, and staff interviews revealed confusion over who was responsible for providing and documenting the bed hold information. No documentation was found in the resident's record to show that the required notice was given.
The facility's medication error rate exceeded 5% due to two incidents: an LPN crushed and administered atorvastatin calcium tablets to a resident with kidney and neurological conditions, despite this being contraindicated, and another LPN gave two scoops of polyethylene glycol to a resident with neurological deficits instead of the prescribed one scoop, based on the resident's request and without provider approval.
A resident with a history of medical conditions was in visible distress and pain, yet the facility staff failed to provide adequate pain management. Despite having an order for a stronger medication, only Tylenol and Zofran were administered, which were ineffective. The resident's condition worsened throughout the day, and she was eventually sent to the hospital with a diagnosis of colitis. Interviews revealed a lack of urgency in addressing the resident's needs, leading to actual harm.
The facility inaccurately reported staffing data to CMS for Q1 2024, resulting in a One-Star Staffing Rating. The PBJ report showed issues such as missed deadlines, insufficient RN staffing hours, and audit failures. The facility's assessment recommended four RNs for its 173-bed capacity and 145 average daily census. The DON and Administrator acknowledged the rating, citing high turnover and agency reliance.
A medication error rate of 11.11% was identified when an LPN administered medications to a resident with hypertension and cerebral infarction too early, outside the facility's policy of a 60-minute window around the scheduled time. The LPN adjusted the timing for residents in the skilled hall, and the ADON confirmed the error, noting that exceptions require physician approval.
A facility failed to ensure consistent documentation of a resident's code status, with discrepancies between the EMR, physician orders, and POLST. Staff interviews revealed confusion, as the EMR and orders indicated a DNR status, while the POLST showed a Full Code. The DON confirmed the expectation for consistent documentation, which was not met.
A resident with contracted hands did not receive adequate ADL care, resulting in poor nail care and hand hygiene. Despite being cognitively intact and dependent on staff for ADL care, the resident expressed dissatisfaction with the care provided. Observations showed dirty and untrimmed nails, and staff interviews confirmed that the facility's ADL protocols were not followed, leading to unmet care needs.
A resident with a urostomy was sent to an outside appointment without a urostomy bag, as the facility ran out of supplies. The resident's stoma was covered with an adult brief and a disposable bed pad. The incident was reported by the resident's caseworker, and the facility staff explained that the resident had removed the appliance before leaving. The Administrator noted that the supplies were special-order items not available through usual resources.
The facility failed to follow infection control practices by not bagging a resident's C-PAP mask when not in use and an LPN handling medications with bare hands. The C-PAP mask was found unbagged on a resident's bed, contrary to policy, and the LPN admitted to touching medications with bare hands, which is against infection control protocols.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinence Care
Penalty
Summary
The deficiency involves failure to follow the facility’s infection prevention and control and hand hygiene policies during incontinence care for one resident. The facility’s Infection Prevention and Control Program Description policy requires implementation of control measures and precautions, including hand hygiene, and the Hand Hygiene policy requires all staff to perform proper hand hygiene consistent with accepted standards of practice. The resident involved had diagnoses including contractures of both hands, UTI, and muscle weakness, with a BIMS score indicating moderately impaired cognition, and was care planned as bowel and bladder incontinent with staff responsible for cleaning the perineal area and changing briefs and clothing as needed after incontinence episodes. During observed incontinence care, a CNA did not perform hand hygiene between glove changes. The CNA acknowledged that she failed to sanitize her hands after removing used gloves and before donning a new pair and stated she should have done so. The SDC and DON both stated in interviews that staff are expected to wash or sanitize hands between glove changes and that failure to do so could result in spread of germs, cross-contamination, or infection to residents. These observations and interviews showed that staff actions during incontinence care did not comply with the facility’s established hand hygiene and infection control policies.
Failure to Provide Suitable Call Device for Dependent Resident
Penalty
Summary
A resident with a history of cervical spinal cord injury and schizophrenia, who was dependent for all activities of daily living and had upper extremity impairment, was not provided with a call device suitable for her use. Despite the call light being placed within her reach, the resident was unable to activate it due to her physical limitations, as observed on multiple occasions. Staff interviews confirmed awareness of the resident's inability to use the standard call button, and documentation revealed that the care plan did not address her inability to use the call device. The deficiency was further evidenced by the lack of an appropriate assessment upon admission to determine the resident's need for a specialized call device. Both nursing and administrative staff acknowledged that the resident required a different type of call light, but no suitable device was provided during the period reviewed. The resident had to wait for staff to check on her for assistance, as she could not independently call for help.
Failure to Provide Written Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice or reason for transfer to a resident and their representative at the time of two separate hospital transfers. According to the facility's own policy, written information regarding bed hold practices must be given both in advance and at the time of transfer for hospitalization or therapeutic leave. Record review showed that the resident was not cognitively intact at the time of the transfers, and there was no documentation in the clinical record that the required notices were provided for either transfer. Interviews with the resident's representative confirmed that no written bed hold notice was received, and this was the first time the representative had heard of the term 'bed hold.' Staff interviews revealed confusion and lack of clarity regarding responsibility for providing and documenting the bed hold notice. Nursing staff believed the business office or admissions was responsible, while the business office manager stated it was the nursing staff's duty to provide the notice at the time of transfer. The unit manager indicated that providing the bed hold policy was part of the transfer process, but acknowledged there was no documentation of this action. The administrator was unable to locate any proof that the required written notice was given for the hospital transfers, despite expectations that nursing staff would provide and document the notice in the resident's record.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in a calculated error rate of 7.69 percent. This was determined through observations, staff and resident interviews, and record reviews. For one resident with diagnoses including hyperkalemia, acute kidney failure, and encephalopathy, an LPN crushed and administered atorvastatin calcium oral tablet, despite the medication not being approved for crushing. The LPN acknowledged the error, and the facility pharmacist confirmed that atorvastatin calcium tablets should not be crushed. The Director of Nursing also confirmed that nurses are expected to follow the facility's policy and reference materials regarding medication administration. In another instance, a resident with a history of hemiplegia, hemiparesis, dysarthria, anarthria, and muscle weakness was ordered to receive one scoop of polyethylene glycol powder daily for constipation. However, an LPN administered two scoops after the resident requested an additional dose, without provider approval. The LPN confirmed the deviation from the physician's order, and the Director of Nursing stated that any changes to medication administration require prior provider approval. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, R117, who was in distress and exhibiting signs of pain. Despite having an active order for a stronger pain medication, Tramadol, the staff only administered Tylenol and Zofran, which were ineffective. Observations on the day of the incident revealed that R117 was in significant pain, rocking, moaning, and vomiting, yet the staff did not assess her condition adequately or administer the stronger medication available. The resident, R117, had a history of conditions including gastroparesis, diabetes, and systemic inflammatory response syndrome. Her care plan included interventions for pain management, but these were not followed. On the day of the incident, the LPN on duty prioritized medication pass over attending to R117's immediate needs, despite her visible distress and requests for assistance. The resident's condition worsened throughout the day, and she was eventually sent to the hospital with a diagnosis of colitis. Interviews with staff revealed a lack of urgency in addressing R117's pain and distress. The LPN initially dismissed the resident's request for help, and the Director of Nursing only intervened after being informed by the surveyor. The facility's failure to adhere to its pain management policy and to respond promptly to the resident's needs resulted in actual harm to R117, who was left in pain and distress for several hours before being sent to the hospital.
Inaccurate Staffing Data Reporting Leads to One-Star Rating
Penalty
Summary
The facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of Fiscal Year 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) report, which indicated a One-Star Staffing Rating due to several issues: failure to submit PBJ data by the deadline, more than four days in the quarter without Registered Nurse (RN) staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. The facility's assessment tool indicated a licensed bed capacity of 173 beds with an average daily census of 145 residents, recommending four RNs based on resident acuity levels. Interviews with the Director of Nursing (DON) and the Administrator revealed awareness of the staffing rating issue, attributing it to high turnover rates and reliance on staffing agencies.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.11% during the survey. This deficiency was identified through observations, record reviews, and staff interviews. Specifically, the error involved the administration of medications to a resident, R124, who had diagnoses including hypertension and cerebral infarction. The medications, which included carvedilol, baclofen, and apixaban, were ordered to be administered at 9:00 am but were given at 7:13 am by an LPN, outside the facility's policy of administering medications within 60 minutes of the scheduled time. The LPN acknowledged administering the medications too early and stated she had adjusted the timing for residents in the skilled hall due to varying needs, such as pain management before therapy. The Assistant Director of Nursing confirmed that the administration time was incorrect and noted that exceptions to the timing policy should be documented and approved by a physician. The failure to adhere to the scheduled medication administration times as per the physician's orders and facility policy led to the identified deficiency.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that the code status for one of the residents, identified as R111, was consistently documented and available to the staff responsible for the resident's care. The facility's policy on Residents Rights Regarding Treatment and Advanced Directives requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team. However, there was a discrepancy in the documentation of R111's code status. The Electronic Medical Record (EMR) and physician orders indicated a Do Not Resuscitate (DNR) status, while the Physician Orders for Life Sustaining Treatment (POLST) documented a Full Code status, signed by two physicians and the resident's responsible party. Interviews with staff, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), a Hospice Registered Nurse (RN), and the Director of Nursing (DON), revealed inconsistencies in the understanding and documentation of R111's code status. The CNA and LPN referred to the EMR for code status information, which showed a DNR status, while the Hospice RN confirmed a Full Code status as per the POLST. The DON acknowledged the expectation for the code status to be easily located and consistent across the EMR, orders, and miscellaneous documents, which was not the case for R111.
Inadequate ADL Care for Resident with Contracted Hands
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident with contracted hands, resulting in poor nail care and hand hygiene. The resident, identified as R4, was admitted with multiple diagnoses including chronic respiratory failure, chronic kidney disease, Alzheimer's disease, hypertension, chronic obstructive pulmonary disease, and a psychotic disorder. Despite being cognitively intact with a BIMS score of 15, R4 was dependent on staff for ADL care. The care plan indicated a self-care deficit requiring assistance with ADL care due to physical limitations and multiple comorbidities, with a preference for bed baths. Observations and interviews revealed that R4 had dirty fingernails digging into her skin and expressed dissatisfaction with the frequency and quality of care. On multiple occasions, R4 was observed with unclean hands and nails, and her fingernails were untrimmed and contracted into her skin. A CNA confirmed that ADL care should include hand and nail care, and a LPN stated that the facility's ADL protocols should encompass comprehensive hand cleaning, with only nurses permitted to cut nails if the resident is diabetic. The LPN confirmed that R4 prefers her nails short and clean, indicating a failure to meet the resident's care needs.
Failure to Provide Urostomy Care
Penalty
Summary
The facility failed to provide appropriate urostomy care for a resident, identified as R262, who was sent to an outside appointment without a urostomy bag. R262 had a urostomy with an ileal conduit due to bladder cancer and was admitted with diagnoses including malignant neoplasm of the posterior wall of the bladder and surgical aftercare of the genitourinary system. The care plan for R262 included interventions such as educating the resident on the importance of keeping a urostomy bag and providing urostomy care as ordered. However, on the day of the appointment, the resident was sent out without the necessary urostomy appliance, which was covered with an adult brief and a disposable bed pad instead. The incident was reported by the resident's caseworker, who informed the facility that Adult Protective Services had been notified. The facility's staff explained that the resident had removed the appliance before leaving and that there were no additional supplies available to reapply it. The Director of Nursing, who was not employed at the time of the incident, confirmed that residents should not be sent out without the appropriate ostomy bag. The Administrator stated that the resident's supplies were special-order items not available through the facility's usual supply resources, and the shipment had not arrived in time for the appointment.
Infection Control Deficiencies in Respiratory and Medication Handling
Penalty
Summary
The facility failed to adhere to standard infection control practices, as evidenced by two specific incidents. In the first incident, a continuous positive airway pressure (C-PAP) mask belonging to a resident was observed unbagged and lying on a towel on the resident's bed. The resident mentioned that he cleans the machine himself daily. A Licensed Practical Nurse (LPN) confirmed that the mask was not bagged, which was against the facility's policy that requires respiratory equipment to be covered in a plastic bag when not in use. Both the Director of Nursing and the Administrator stated that it is the responsibility of the nursing staff to ensure that C-PAP masks are clean and bagged when not in use. In the second incident, an LPN was observed handling medications with her bare hands during medication administration. The facility's policy explicitly states that medications should not be touched with bare hands to prevent contamination or infection. The LPN admitted to handling the medications with her bare hands, citing that her hands were too big and she did not want to drop the medications. The Assistant Director of Nursing confirmed that the expectation is for nurses to avoid touching medications with bare hands and to use gloves if necessary. These actions were in direct violation of the facility's infection control protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 275 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Conyers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockdale Healthcare Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Pruitthealth - Lithonia, Llc | 6.9 mi | ★★★★★ | 9 | 0 |
| Riverside Health Care Center | 9.1 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Covington | 9.5 mi | ★★★★★ | 4 | 0 |
| Parkside Post Acute And Rehabilitation | 10.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Westbury Center Of Conyers For Nursing And Healing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.