Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Jackson For Nursing And Healing during CMS and state inspections, most recent first.
Improper storage of non-linen items on linen carts was observed on multiple halls, where carts contained food items, gloves, and other miscellaneous items, and a resident towel was placed on top of an uncovered cart. The ADON stated this was not acceptable and identified infection as the hazard, and the DON and Administrator confirmed linen carts were to contain clean linens only and not be used to store or transport non-linen items.
A resident with severe cognitive impairment did not receive personal care in a manner that maintained their dignity and privacy. A CNA provided care with the room door open and the privacy curtain partially drawn, which was confirmed by an LPN and the DON as not meeting the facility's protocol for ensuring resident privacy.
Two residents were found with medications at their bedside without being assessed for self-administration. One resident with severe cognitive impairment had eye drops, while another with little cognitive impairment had multiple nasal spray bottles. Staff interviews revealed a lack of adherence to the facility's policy requiring assessments and physician's orders for self-administration, placing residents at risk of medication misuse.
The facility failed to maintain clean PTAC filters in two resident rooms, with one filter torn and both covered in debris. The Maintenance Director confirmed the need for cleaning and replacement, despite monthly checks. Additionally, chipped paint and detached baseboards were observed in two bathrooms, with the MD acknowledging the issues and noting he had been working alone.
The facility failed to submit Level II PASARR applications for three residents with mental disorders or intellectual disabilities, as required by policy. The Social Services Director was unaware of her responsibility to identify and refer residents for Level II evaluations, resulting in residents with conditions like bipolar disorder, depression, and psychosis not being evaluated for specialized services.
A resident with a history of stroke and muscle contracture did not receive prescribed restorative nursing care, including passive range of motion exercises and the use of a splint, due to a lack of awareness among CNAs and the absence of the splint in the resident's room. The Director of Rehabilitation confirmed the need for the splint, but it was not applied as required.
The facility exceeded the acceptable medication error rate, reaching 6.67% due to improper insulin administration to two residents. The CMA failed to hold the insulin pen needle in place for the required time, potentially leading to incomplete doses. This was against the facility's policy, as confirmed by staff interviews.
A resident in an LTC facility, who was legally blind and had a history of depression and anxiety, was verbally and physically abused by a CNA. The CNA made racial and sexual comments, causing the resident distress and fear. The resident attempted to leave but was physically blocked and restrained by the CNA. The incident was witnessed by another staff member and a resident, and the facility's investigation confirmed the abuse, leading to the termination of the involved CNAs.
A facility failed to notify a resident's representative of changes in the resident's condition, including refusal of medication, meals, therapy, and ADL care, as well as complaints of stomach pain. The resident was eventually sent to the emergency room for acute abdominal pain, and family members reported not being informed of these issues. The DON confirmed that the responsible party should have been notified and documentation should have been made.
Improper Storage of Non-Linen Items on Linen Carts
Penalty
Summary
Provide and implement an infection prevention and control program was cited after observations and staff interviews showed that linen carts on the 200 Hall, 400 Hall, 600 Hall, and 800 Hall were stocked with non-linen items, including food items, gloves, and other miscellaneous items. A resident's towel was also observed placed on top of a linen cart that was not covered. The facility policy required laundry and direct care staff to handle, store, process, and transport linens to prevent the spread of infection, and to keep clean linen separated from soiled linen at all times. During interview, the ADON stated that leaving non-linen items on the linen cart was not acceptable and identified infection as the potential hazard. After the interview, the ADON removed the non-linen items from the linen cart. The DON and Administrator later confirmed that linen carts were required to contain clean linens only and were not to be used to store or transport non-linen items, and they acknowledged that the observed condition was not consistent with facility expectations.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain or enhance the dignity of a resident, identified as R37, during personal care activities. R37, who has severe cognitive impairment due to conditions such as senile degeneration of the brain and dementia, required assistance with activities of daily living (ADLs). During an observation, a Certified Nurse Assistant (CNA) was seen providing personal care to R37 with the room door open and the privacy curtain only partially drawn, which did not ensure complete privacy for the resident. Interviews with staff confirmed the deficiency in maintaining privacy. A Licensed Practical Nurse (LPN) acknowledged that the door should have been closed to protect the resident's privacy, and the privacy curtain should have been fully drawn. The CNA admitted to providing care with the door open and not fully utilizing the privacy curtain, contrary to the facility's protocol. The Director of Nursing (DON) also confirmed the expectation that doors should be closed and privacy curtains fully drawn during personal care to ensure resident privacy.
Failure to Assess and Monitor Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside of two residents, R86 and R287, who were not assessed for medication self-administration. R86, who has severe cognitive impairment due to dementia, was found with Visine A.C. Itchy Relief eye drops on her bedside table. She did not remember how the eye drops got there and stated that staff were aware of their presence. The facility's policy requires an interdisciplinary team assessment before a resident can self-administer medication, but R86 had no such assessment, care plan, or physician's order for self-administration. R287, who has a history of stroke and other medical conditions but little to no cognitive impairment, was found with eight bottles of Afrin nasal spray scattered throughout his room. There was no physician's order, assessment, or care plan for R287 to self-administer medications. The presence of these medications was not questioned by the nurse during a medication pass, and the nasal spray bottles remained in the room. Interviews with facility staff, including CNAs, LPNs, the DON, and the Administrator, revealed a lack of awareness and adherence to the facility's policy on medication self-administration. Staff confirmed that residents must have a physician's order and assessment to self-administer medications, and that medications should not be left at the bedside without proper authorization. The failure to follow these protocols placed the residents at risk of medication misuse or overdose.
Deficiencies in PTAC Filter Maintenance and Room Conditions
Penalty
Summary
The facility failed to maintain clean PTAC filters in two resident rooms, as observed during a survey. In one room, the PTAC filter was torn and covered with gray, fuzzy debris, while in another room, the filter also had gray, fuzzy debris. The Maintenance Director (MD) confirmed these observations and acknowledged that the filters needed cleaning and replacement. The MD stated that filters were checked monthly and cleaned as needed, but the presence of debris indicated a lapse in maintenance. The Administrator believed the filters were cleaned monthly, aligning with the facility's expectations. Additionally, the facility did not maintain a homelike environment in two resident rooms, where chipped paint and detached baseboards were observed in the bathrooms. The MD confirmed these maintenance issues and explained that staff should report such concerns through the electronic maintenance system or directly to him. However, he noted that he had been working alone, which may have contributed to the oversight. These deficiencies potentially placed residents at risk of living in an unsanitary and unsafe environment.
Failure to Submit Level II PASARR Applications for Residents
Penalty
Summary
The facility failed to submit applications for Level II PASARR evaluations for three residents who were identified with mental disorders or intellectual disabilities. The facility's policy requires coordination with the PASARR program to ensure residents receive appropriate care and services. However, the Social Services Director was unaware of her responsibility to determine which residents required Level II PASARR submissions. This oversight resulted in residents with diagnoses such as bipolar disorder, depression, anxiety disorder, psychosis, and major depressive disorder not being evaluated for specialized services. Resident 32 had diagnoses of bipolar disorder, depression, and anxiety disorder, but these were not documented in the PASARR Level 1 Assessment Form. Similarly, Resident 87 had diagnoses of psychosis, anxiety disorder, and major depressive disorder, which were also not documented. Resident 90 had diagnoses of depression, psychosis, and bipolar disorder, yet these were missing from the PASARR Level 1 Assessment Form. The Social Services Director confirmed the oversight, and the Administrator acknowledged the failure to submit the necessary applications for these residents.
Failure to Provide Restorative Nursing Care for ROM and Mobility
Penalty
Summary
The facility failed to provide restorative nursing care for a resident, identified as R99, who required range of motion (ROM) and mobility assistance. R99 had a history of a cerebral infarction resulting in hemiplegia and hemiparesis, and was diagnosed with a contracture of the muscle in the left upper arm. Despite having a physician's order for nursing restorative care and specific instructions from occupational therapy for passive range of motion exercises and the use of a resting hand splint, these interventions were not observed to be implemented. Observations over several days revealed that R99 did not have the prescribed splint on her left upper extremity, and interviews with certified nursing assistants (CNAs) indicated they were unaware of the need for the splint. The Director of Rehabilitation confirmed that R99 was admitted with a splint and required it to prevent further contracture. However, the splint was not present in the resident's room, and the CNAs responsible for applying it were not informed of its necessity. The Director of Nursing stated that the expectation was for CNAs and nurses to follow therapy instructions regarding splint application, but this was not done, leading to a deficiency in care for R99.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.67 percent due to two errors out of 30 opportunities. This deficiency was identified through observations, staff interviews, and record reviews, specifically involving two residents, R119 and R147, who were administered insulin injections incorrectly. The facility's policy on insulin pen usage, revised in August 2023, requires that the pen needle be held in place for ten seconds after injection to ensure the full dose is delivered. However, this procedure was not followed during the administration of insulin to the residents. Resident R119, diagnosed with type 2 diabetes mellitus and diabetic chronic kidney disease, was observed receiving an insulin glargine injection. The Certified Medical Assistant (CMA) administering the injection removed the pen needle immediately after injection, contrary to the policy. Similarly, Resident R147, also diagnosed with type 2 diabetes mellitus, received a Fiasp Flex insulin injection, and the CMA again removed the pen needle immediately after injection. Interviews with the CMA and the Staff Educator confirmed that the expected procedure was not followed, potentially leading to incomplete doses being administered to the residents.
Resident Abused by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by staff, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who made racial comments and physically restrained the resident. The resident, who was legally blind and had a history of major depressive disorder and anxiety disorder, was subjected to verbal abuse that caused significant distress. The incident occurred when the resident was waiting for a shower, and the CNA made inappropriate racial and sexual comments, leading the resident to become distraught and fearful. The facility's investigation revealed that the resident attempted to leave the room but was physically blocked by the CNA, who forcefully pushed the resident down and grabbed the wheelchair. The resident's attempts to leave were met with laughter and further intimidation by the CNA, causing the resident to cry and become increasingly agitated. The incident was witnessed by another staff member and a resident, both of whom confirmed the resident's account of events. The facility's policy on abuse, neglect, and exploitation was not adhered to, resulting in a violation of the resident's rights. The investigation included a review of camera footage, which corroborated the resident's claims of being blocked and circled in the room by the CNA. Despite the lack of audio, the visual evidence supported the resident's account of the incident. The police were involved, and the facility terminated the employment of the two CNAs involved. The resident's responsible party was notified, and the resident left the facility, not returning due to the trauma experienced.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in the resident's condition, as required by their policy titled 'Notification of Changes.' The resident, identified as R5, had a Brief Interview for Mental Status (BIMS) score indicating intact cognition and was new to the facility. Despite the care plan directing staff to notify the resident's family of changes in condition, there was no evidence that the family or responsible party was informed of the resident's refusal of medication, meals, therapy, and Activities of Daily Living (ADL) care, or the resident's complaint of stomach pain. The deficiency was highlighted when the resident was sent to the emergency room for acute abdominal pain, and family members reported not being notified of the resident's condition. Interviews with family members revealed that they were unaware of the resident's refusals and condition changes. The Director of Nursing confirmed that the resident's responsible party should have been notified of any changes in treatment or condition, and such notifications should have been documented in the resident's progress notes.
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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.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Monroe | 10.4 mi | ★★★★★ | 0 | 0 |
| Westbury Center Of Mcdonough For Nursing & Healing | 14.1 mi | ★★★★★ | 3 | 2 |
| Retreat, The | 16.7 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Griffin | 16.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Forsyth | 17.8 mi | ★★★★★ | 7 | 0 |
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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.