Cycle 1
Health 2025-06-27 · Fire 2025-06-27
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mcdonough, GA
Westbury Center Of Mcdonough For Nursing & Healing
1-star overall rating with 1-star inspections with abuse icon flag with 5 recent health deficiencies
198 Hampton Street, Mcdonough, GA
(770) 957-9081
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
210
Certified beds
Average residents
147
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Empire Care Centers
Operator or chain grouping
Approved since
1989-12-01
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
0.30
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,839
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.07% · Performance 22.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.37
Baseline 12.79% · Performance 9.77% · Measure score 3.37 · Achievement 0 · Improvement 3.37
Total nurse turnover
0.69
Performance 60.87% · Measure score 0.69 · Achievement 0.69 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 12.5% · Lower 95% interval 8.04% |
| Discharge to community | 46.06% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 37.38% · Lower 95% interval 38.04% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.19% |
95.27%
2.9 pts better
|
Numerator 163 · Denominator 166 |
| Falls with major injury | 1.81% |
0.77%
1 pts worse
|
Numerator 3 · Denominator 166 |
| Discharge self-care score | 39.58% |
53.69%
14.1 pts worse
|
Numerator 38 · Denominator 96 |
| Discharge mobility score | 23.96% |
50.94%
27 pts worse
|
Numerator 23 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 166 · Adjusted rate 0.83% |
| Healthcare-associated infections requiring hospitalization | 9.77% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 14.46% · Lower 95% interval 6.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 23.31% |
42%
18.7 pts worse
|
Numerator 31 · Denominator 133 |
| Discharge function score | 40.63% |
56.45%
15.8 pts worse
|
Numerator 39 · Denominator 96 |
| Transfer of health information to provider | 91.43% |
95.95%
4.5 pts worse
|
Numerator 64 · Denominator 70 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 12.84% |
25.2%
12.4 pts worse
|
Numerator 14 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.0
1.6 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 31.0% |
91.2%
60.2 pts worse
|
93.4%
62.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 30.8% · Q3 31.7% · Q4 29.3% · 4Q avg 31.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.5% |
95.0%
19.5 pts worse
|
95.5%
20 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.2%
1.4 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.8% · Q3 6.5% · Q4 4.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
9.6%
6.2 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.0% · Q3 2.7% · Q4 2.6% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
5.9%
2.9 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.4% · Q3 10.1% · Q4 7.5% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
20.7%
8.3 pts better
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.1% · Q3 12.4% · Q4 13.3% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
21.4%
10.8 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.0% · Q3 7.1% · Q4 10.2% · 4Q avg 10.6% · 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 | 12.8% |
17.9%
5.1 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 14.9% · Q3 12.0% · Q4 13.7% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
16.2%
1.6 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 15.0% · Q3 16.5% · Q4 13.3% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.1%
0.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.7% · Q4 0.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.5%
0.2 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.6% · Q3 4.2% · Q4 1.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
16.1%
6.5 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 15.2% · Q3 32.0% · Q4 23.3% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
6.2%
0.1 pts better
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 6.7% · Q3 6.7% · Q4 2.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.7% |
80.4%
42.7 pts worse
|
81.7%
44 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 36.4% · Q3 44.4% · Q4 42.2% · 4Q avg 37.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
12.2%
5.7 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.9% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.2%
1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.3% |
78.2%
46.9 pts worse
|
79.7%
48.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
24.2%
7.2 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 36.6% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Cycle 3
Health 2022-03-15 · Fire 2022-03-15
18 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-04
F · Potential for more than minimal harm
2023-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-04
F · Potential for more than minimal harm
2023-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-04
F · Potential for more than minimal harm
2023-12-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-04
D · Potential for more than minimal harm
2023-12-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-04
D · Potential for more than minimal harm
2023-12-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-04
D · Potential for more than minimal harm
2023-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-04
Inspection history
Recent health citations
K · Immediate jeopardy
2026-01-24
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 2026-01-07
K · Immediate jeopardy
2026-01-24
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-02-21
D · Potential for more than minimal harm
2026-01-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-02-21
G · Actual harm
2025-06-27
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 2025-07-30
E · Potential for more than minimal harm
2025-06-27
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 2025-07-30
F · Potential for more than minimal harm
2023-12-21
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-02-04
E · Potential for more than minimal harm
2023-12-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-04
D · Potential for more than minimal harm
2023-12-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-04
F · Potential for more than minimal harm
2023-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-19
E · Potential for more than minimal harm
2023-05-05
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 2023-06-19
E · Potential for more than minimal harm
2023-05-05
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 2023-06-19
E · Potential for more than minimal harm
2023-05-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-06-19
E · Potential for more than minimal harm
2023-05-05
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-06-19
E · Potential for more than minimal harm
2023-05-05
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 2023-06-19
E · Potential for more than minimal harm
2023-05-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-05
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 2023-06-19
D · Potential for more than minimal harm
2023-05-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-05
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-19
G · Actual harm
2022-03-15
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 2022-04-22
G · Actual harm
2022-03-15
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 2022-04-22
G · Actual harm
2022-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-22
F · Potential for more than minimal harm
2022-03-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-22
F · Potential for more than minimal harm
2022-03-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-15
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-04-22
Penalties and ownership
What sits behind the stars
Ownership
Ga4 Opco Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Empire Care Centers LLC
Operational/Managerial Control · Organization
Ensh Consulting LLC
5% Or Greater Indirect Ownership Interest · 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
Pittman, Jacqueline
Operational/Managerial Control · Individual
Pittman, Jacqueline
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Laurel Park, LLC
Stockbridge, GA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Jonesboro Center for Nursing and Healing LLC
Jonesboro, GA
4-star overall rating with 4-star inspections with $16,801 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Griffin
Griffin, GA
1-star overall rating with 2-star inspections with 3 recent health deficiencies
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