Westbury Center Of McDonough For Nursing & Healing
198 Hampton Street, McDonough, GA 30253 · For profit - Limited Liability company · 210 certified beds · (770) 957-9081 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
- it has a citation for mishandling residents’ money or property (F0568)
- it has 4 actual-harm citations
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.4% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.2% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 2.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.5% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 12.3% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.6% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 75.5% | 95.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.8% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 24.6% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 31.3% | 78.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 31.2% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.5% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.37 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.91 | 1.90 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 107 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 113 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.1%CMS range 38.0–55.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.0–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 43.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 92.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.8%CMS range 6.4–15.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 210 beds and averages 147.5 residents a day — about 70% occupied, or roughly 62 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.62 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.76 hrs/resident/day on weekends vs 3.23 on weekdays — 14% thinner on weekends. RN hours go from 0.38 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
12 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · Jcited before2026-01-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and a review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect the Resident's (R) (R1) right to be free from sexual assault by Environmental Service (EVS) Housekeeper EE. The sample size was eight.On January 20, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations, and Regional Director of Operations (RDOP) were informed of the Immediate Jeopardy (IJ) on January 20, 2026, at 5:10 pm. The noncompliance related to the IJ was identified to have existed on January 6, 2026.An Acceptable IJ removal Plan was received on January 23, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-06-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect four of 19 residents (R) (R200, R60, R66, and R73) right to be free from physical abuse by R154 and R160. Specifically, the facility failed to ensure R60 was free from physical abuse by R160 resulting in scratches on the face and R154's abuse towards R66 that resulted in actual harm when she sustained a sprained ankle and required an emergency room (ER) visit where an ankle immobilizer was initiated. R154's abuse towards R73 resulted in psychosocial harm using the reasonable person concept when dragged and pinned to the floor by R154. Findings include: Review of the facility's Abuse, Neglect, and Exploitation, policy dated 4/2024 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2022-03-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of the facility policies titled Notification of Changes and Accidents/Incidents, the facility failed to promptly notify the Physician and responsible party (RP) timely for a change in condition including a fall and self-injurious behavior after a fall for one of three residents (R) R#119. Actual harm occurred when R#119 had a fall on 2/19/2022 and suffered a laceration to the residents' scalp that required 10 staples and the resident exhibited a change in behavior of banging his head on doorframe of bathroom. The Physician was not notified until the following day at 4:25 p.m., 37 hours after the residents fall. Findings include: Review of the facility policy titled, Notification of Changes dated November 2017 revealed the purpose is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring a notification.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2022-03-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and review of the facility policy titled Abuse Prohibition, the facility neglected to ensure that one of three residents (R) R#119 received timely treatment following a fall and change of condition. Actual harm was identified to have occurred on 2/19/2022 when R#119 had a fall and suffered a laceration to the scalp which required 10 staples. The facility neglected to send the resident to the emergency room (ER) for treatment of the laceration on his head for 37 hours after the resident fell. Findings include: Review of the facility policy titled Abuse Prohibition dated 8/2019, revealed the policy is to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses of but not limited to fracture…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2022-03-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy titled Person Centered Care Plan, the facility failed to implement the person-centered care plan for one resident (R) R#119 care plans reviewed, related to notifying the Physician after a fall. Actual harm was identified to have occurred on 2/19/2022 when R#119 had a fall and suffered a laceration to the scalp which required 10 staples. In addition, the facility failed to follow the care plan for one resident (R#24) reviewed for active range of motion (AROM) to bilateral upper extremities. The sample size was 38. Findings include: Review of the undated facility policy titled, Person Centered Care Plan revealed the purpose is to structure and guide therapeutic interventions to meet patient needs and achieve expected outcomes. Practice standards include develop individualized plan of care based upon social history and initial assessments, Care Area Assessment (CAA) triggers, and observations. Review, evaluate, and update care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to ensure the environment was homelike, i.e. clean and comfortable, for five residents (R) (R42, R79, R80, R84, R122) attending the resident council interview, for 14 residents residing on the [NAME] Unit in rooms R32, R33, R34, R40, R45, R47, and R48 and for all 44 residents residing on the Heritage Unit and for one resident (R400) residing on the Memory Care Unit out of a total census of 143 residents. Findings include: Review of the facility's Safe and Homelike Environment policy dated 4/2025 and provided by the facility revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . A homelike environment is one that de-emphasizes the institutional character of the setting . Orderly is defined as an uncluttered physical environment that is neat and well-kept . Housekeeping and maintenance services will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-21 · tag F0568 — widespreadProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff and resident interviews, and review of the facility policy titled Transactions Involving Resident Funds the facility failed to provide quarterly resident trust fund statements to 82 of 82 residents who have a resident account in the facility. Findings include: Review of the facility policy titled Transactions Involving Resident Funds revised 1/11/2023 revealed: 8. Quarterly statements will be provided in writing to the resident, or the resident's representative within 30 days after the end of the quarter and upon request. Interview on 12/19/2023 at 12:26 pm during the Resident Council meeting with R26 revealed nobody here knows how much money they have. R26 stated they were supposed to have $330.00 but had not received a quarterly statement so she was unsure of the exact amount available to her. Interview on 12/19/2023 at 2:30 pm with R96 revealed because they are not getting quarterly statements. They did not know exactly how much was in their accounts. Interview on 12/20/2023 at 8:30 am with the Business Office Manager (BOM) revealed she provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-21 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policies titled, Dialysis: Hemodialysis (HD) - Communication and Documentation and Hemodialysis (HD) Provided by a Certified Dialysis Facility, the facility failed to maintain consistent communication with the dialysis center for three of eight residents (R) (R109, R2, and R381) receiving dialysis. Specifically, the facility failed to review the communication forms upon residents' return to the facility from the dialysis center and to notify the dialysis center when their portion was not completed. Findings include: Review of the undated facility policy titled Dialysis: Hemodialysis (HD) - Communication and Documentation revealed the policy of the facility is to communicate with the certified dialysis facility prior to sending a patient for hemodialysis (HD) by completing the Hemodialysis Communication Record and sending the document with the resident. The form will also be completed upon the return of the patient from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Safety, the facility failed to ensure O2 administered by nasal cannula (NC) was set at the rate prescribed by the physician for one of 25 residents (R) (R1) receiving O2 therapy. The deficient practice had the potential to cause R1 respiratory distress. Findings include: Review of the facility policy titled Oxygen Safety date reviewed/revised June 2023, revealed under the section titled Policy: 1. It is the policy of this facility to provide a safe environment for residents, staff, and the public. Under Policy Explanation and Compliance Guidelines: 1. Safety is the responsibility of all staff, residents, visitors, and the public. Review of the electronic medical record EMR) the quarterly Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 3, which is indicative of severe cognitive impairment. The pertinent diagnoses included heart failure and cerebral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-03-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interviews, the facility failed to maintain a sanitary condition for one of three ice machines used in the daily operation of dining services. The facility census was 133 residents. Findings include: Observation on 2/20/2022 at 4:35 p.m. with Certified Dietary Manager (CDM) revealed three ice machines in the facility. The ice machine located inside the kitchen was observed to have a dark, rust-colored substance on the inside hinge of the lid. Further observation revealed dust buildup on both side filters, and dust buildup on the back side of the unit. Observation on 2/21/2022 at 10:07 a.m. and 1:12 p.m. revealed the ice machine in the kitchen continued to have dark substance on the inside hinges of the lid. Interview on 2/20/2022 at 4:35 p.m. with the CDM, confirmed the ice machine had dust buildup on two side filters and on the back of the unit as well as the dark, rust-colored substance on the hinge of the lid. The CDM stated the Maintenance department was responsible for cleaning the ice machine, but revealed she was not sure how often it is done.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-03-15 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews and review of policy titled, Antibiotic Stewardship Program, the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for nine months (January 2021 through September 2021). The facility census was 133. Findings include: Review of the facility policy titled Antibiotic Stewardship Program dated August 2019, revealed the Antibiotic Stewardship Program's (ASP) action is to improve antibiotic use adverse events, prevent emergence of resistance, and lead to better outcomes for patients and residents in this setting. The ASP is based on The Core Elements of Antibiotic Stewardship for nursing Homes, which include Leadership, Accountability, Drug Expertise, Action, Tracking, Reporting and Education. Core element 5. Tracking-monitor measures of antibiotic use by auditing available reports and patient medical records for adherence, monitor if cultures obtained before antibiotics initiated, if indicated, and if antibiotics changed during course of treatment, monitor rates of new antibiotic starts/1,000 resident-days…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility policy titled Restorative Nursing, the facility failed to provide restorative nursing services for one resident (R), R#2 as ordered by the physician. Resident #2 had Physician orders dated 7/1/2021 for Restorative Nursing services. The sample size was 38 residents. Findings include: Review of the undated facility policy titled, Restorative Nursing, revealed the purpose is to promote the patient's ability to adapt and adjust to living as independently and safely as possible and help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Practice Standards: 4. Implement the restorative nursing program according to the specifics on the care plan. 6. Document daily in electronic medical record (EMR) point of care (POC). Review of the clinical record for R#24 revealed she was admitted to the facility on [DATE] with diagnoses of but not limited to chronic respiratory failure with hypoxia, emphysema, chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to EMPIRE CARE CENTERS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 19 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GA4 OPCO HOLDING LLC | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2021 |
| ENSH CONSULTING LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2021 |
| HELLER, SHLOMO | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| NUSSBAUM, EPHRAIM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| SWERDLOFF, ARYEH | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| DONATH, BARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/07/2021 |
| EMPIRE CARE CENTERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| BONNER, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/27/2023 |
| CHAMBLIN, DIANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/2022 |
| DUNNING, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/2025 |
| ELLIS, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| HARDY, LEANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| MCKENZIE, ROSEMARIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/03/2024 |
| REED, JOEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2023 |
| RYAN, VICKI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| SMITH, DEAYSIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/07/2021 |
| SONE-EBELOUE, GLADYS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| STEPHENS, CARRIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2025 |
| TUCKER, BRITTNEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/06/2024 |
| TWEDELL, GERALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/24/2025 |
CMS files one row per role, so the 45 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115463. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.