Cycle 1
Health 2025-05-22 · Fire 2025-05-22
17 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Atlanta, GA
Westminster Commons
2-star overall rating with 2-star inspections with abuse icon flag with $23,472 in total fines with 17 recent health deficiencies
560 St Charles Ave, Ne, Atlanta, GA
(404) 874-2233
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wellington Health Care Services
Operator or chain grouping
Approved since
2001-10-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 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
0.49
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,880
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.89
Baseline 20.38% · Performance 20.09% · Measure score 2.89 · Achievement 2.89 · Improvement 0.37
Healthcare-associated infections
2.40
Baseline 7.36% · Performance 7.12% · Measure score 2.40 · Achievement 2.40 · Improvement 0.52
Total nurse turnover
0
Performance 62.86% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.22
Baseline 3.37 hours · Performance 3.71 hours · Measure score 2.22 · Achievement 2.22 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 16% · Lower 95% interval 7.37% |
| Discharge to community | 45.7% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 30.95% · Lower 95% interval 31.17% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 36.73% |
95.27%
58.5 pts worse
|
Numerator 18 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 6 · Denominator 24 |
| Discharge mobility score | 12.5% |
50.94%
38.4 pts worse
|
Numerator 3 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 2.31% |
42%
39.7 pts worse
|
Numerator 3 · Denominator 130 |
| Discharge function score | 29.17% |
56.45%
27.3 pts worse
|
Numerator 7 · Denominator 24 |
| Transfer of health information to provider | 60.87% |
95.95%
35.1 pts worse
|
Numerator 14 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24.32% |
25.2%
0.9 pts worse
|
Numerator 9 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
91.2%
3.6 pts worse
|
93.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 94.4% · Q3 80.5% · Q4 80.8% · 4Q avg 87.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.6% |
95.0%
4.4 pts worse
|
95.5%
4.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.2%
2.9 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
9.6%
5.6 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 4.3% · Q4 10.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.9%
0.6 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.2% · Q3 3.2% · Q4 7.1% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
20.7%
9.3 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 9.1% · Q3 10.3% · Q4 13.7% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.9% |
21.4%
6.5 pts worse
|
16.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 35.9% · Q3 28.6% · Q4 22.7% · 4Q avg 27.9% · 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 | 15.8% |
17.9%
2.1 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 10.4% · Q3 12.1% · Q4 13.8% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
16.2%
0.1 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 10.3% · Q3 13.8% · Q4 13.0% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
16.1%
5.9 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 21.1% · Q3 10.2% · Q4 25.0% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
6.2%
0.5 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.2% · Q3 9.0% · Q4 8.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 34.5% |
80.4%
45.9 pts worse
|
81.7%
47.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 37.8% · Q3 28.8% · Q4 22.5% · 4Q avg 34.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
12.2%
5.2 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 20.8% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.2%
0.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.2% |
78.2%
40 pts worse
|
79.7%
41.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.7% |
24.2%
13.5 pts worse
|
23.9%
13.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.7% · Observed 49.1% · Expected 31.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-19 · Fire 2024-01-19
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-03 · Fire 2022-06-03
4 health deficiencies
Top issue: Infection Control (3 deficiencies)
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
2024-01-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-22
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 2025-07-04
E · Potential for more than minimal harm
2025-05-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
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 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
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 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-05-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-04
C · Minimal harm
2025-05-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-04
D · Potential for more than minimal harm
2024-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-01-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
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 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
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 2024-03-04
D · Potential for more than minimal harm
2024-01-19
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 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-03-04
F · Potential for more than minimal harm
2022-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-01
F · Potential for more than minimal harm
2022-06-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-08-01
F · Potential for more than minimal harm
2022-06-03
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-01
Penalties and ownership
What sits behind the stars
$13,674
2024-01-22
Fine
Fine · fine $13,674
Fine
$9,798
2023-12-26
Fine
Fine · fine $9,798
Fine
Ownership
Wellington Healthcare Services LP
5% Or Greater Direct Ownership Interest · Organization
Andrews, James
5% Or Greater Indirect Ownership Interest · Individual
Andrews, James
Operational/Managerial Control · Individual
Andrews, James
Corporate Director · Individual
Andrews, James
Corporate Officer · Individual
Andwell Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Teresa
W-2 Managing Employee · Individual
Elkins Road Associates LLC
General Partnership Interest · Organization
Kelman, Moshe
Corporate Officer · Individual
Wellington Healthcare Services LP
Limited Partnership Interest · Organization
Nearby options
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#2
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3-star overall rating with 3-star inspections with 5 recent health deficiencies
#3
A.g. Rhodes Home, Inc, The
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2-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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