Cycle 1
Health 2025-02-06 · Fire 2025-02-06
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jackson, GA
Westbury Center Of Jackson For Nursing And Healing
2-star overall rating with 3-star inspections with $8,512 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
922 Mcdonough Road, Jackson, GA
(770) 775-7832
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
196
Certified beds
Average residents
189
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Empire Care Centers
Operator or chain grouping
Approved since
1994-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.21
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.92
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,643
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.85
Baseline 18.37% · Performance 19.65% · Measure score 3.85 · Achievement 3.85 · Improvement 0
Healthcare-associated infections
2.64
Baseline 11.09% · Performance 9.18% · Measure score 2.64 · Achievement 0 · Improvement 2.64
Total nurse turnover
1.37
Performance 58.08% · Measure score 1.37 · Achievement 1.37 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.72 hours · Performance 2.83 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 185 · Observed rate 11.89% · Lower 95% interval 8% |
| Discharge to community | 47.65% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 153 · Observed rate 40.52% · Lower 95% interval 39.44% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 71.43% |
95.27%
23.8 pts worse
|
Numerator 130 · Denominator 182 |
| Falls with major injury | 0.55% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 182 |
| Discharge self-care score | 44.25% |
53.69%
9.4 pts worse
|
Numerator 50 · Denominator 113 |
| Discharge mobility score | 45.13% |
50.94%
5.8 pts worse
|
Numerator 51 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 3.3% |
2.29%
1 pts worse
|
Numerator 6 · Denominator 182 · Adjusted rate 2.51% |
| Healthcare-associated infections requiring hospitalization | 9.18% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 13.33% · Lower 95% interval 5.52% |
| Staff COVID-19 vaccination coverage | 2.84% |
8.2%
5.4 pts worse
|
Numerator 5 · Denominator 176 |
| Staff flu vaccination coverage | 8.03% |
42%
34 pts worse
|
Numerator 20 · Denominator 249 |
| Discharge function score | 52.21% |
56.45%
4.2 pts worse
|
Numerator 59 · Denominator 113 |
| Transfer of health information to provider | 93.1% |
95.95%
2.9 pts worse
|
Numerator 54 · Denominator 58 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 57 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 13.33% |
25.2%
11.9 pts worse
|
Numerator 14 · Denominator 105 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
91.2%
1.4 pts worse
|
93.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.0% · Q2 91.2% · Q3 88.2% · Q4 94.6% · 4Q avg 89.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.2%
1.6 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.7% · Q3 5.0% · Q4 4.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
9.6%
1.1 pts better
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 11.2% · Q3 7.0% · Q4 9.9% · 4Q avg 8.5% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.9%
0.2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.5% · Q3 5.1% · Q4 7.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.1% |
20.7%
7.4 pts worse
|
19.6%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 29.6% · Q3 25.9% · Q4 25.9% · 4Q avg 28.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
21.4%
4.7 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 15.0% · Q3 18.6% · Q4 16.1% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.9% |
17.9%
2 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 8.2% · Q3 16.8% · Q4 21.6% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
16.2%
1.2 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 12.1% · Q3 15.0% · Q4 12.3% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.1%
0.9 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.6% · Q4 1.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
16.1%
12.6 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 31.3% · Q3 28.5% · Q4 31.7% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.2%
0.9 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.5% · Q3 3.2% · Q4 6.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
80.4%
9.8 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 92.6% · Q3 90.9% · Q4 87.5% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
12.2%
0.6 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.2%
0.7 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
78.2%
5.5 pts better
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
24.2%
4 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 23.9% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-20 · Fire 2022-01-20
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-06
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2025-03-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-23
D · Potential for more than minimal harm
2025-02-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-23
D · Potential for more than minimal harm
2025-02-06
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-03-23
D · Potential for more than minimal harm
2025-02-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-23
D · Potential for more than minimal harm
2025-02-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-23
D · Potential for more than minimal harm
2025-02-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-23
G · Actual harm
2024-07-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-07-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-15
D · Potential for more than minimal harm
2023-08-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-09
D · Potential for more than minimal harm
2022-01-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-06
Penalties and ownership
What sits behind the stars
$8,512
2024-07-12
Fine
Fine · fine $8,512
Fine
Ownership
Empire Care Centers LLC
Operational/Managerial Control · Organization
Ga4 Opco Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Ga4 Opco Holding LLC
Operational/Managerial Control · Organization
Heller, Shlomo
5% Or Greater Indirect Ownership Interest · Individual
Heller, Shlomo
Operational/Managerial Control · Individual
Heller, Shlomo
Corporate Officer · Individual
Nussbaum, Ephraim
5% Or Greater Indirect Ownership Interest · Individual
Nussbaum, Ephraim
Operational/Managerial Control · Individual
Vasil, Jennifer
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Monroe
Forsyth, GA
4-star overall rating with 4-star inspections
#2
Westbury Center Of Mcdonough For Nursing & Healing
Mcdonough, GA
1-star overall rating with 1-star inspections with abuse icon flag with 5 recent health deficiencies
#3
Retreat, The
Monticello, GA
3-star overall rating with 3-star inspections with $15,269 in total fines with 4 recent health deficiencies
Jump out