Westbury Center of Conyers for Nursing and Healing

In the surveyor’s words

From the most serious findings on record at Westbury Center of Conyers for Nursing and Healing, in the surveyor’s own words.

• Actual harm, isolatedF697May 10, 2024

  Based on observations, record review, interviews, and review of the facility policy titled Pain Management, the facility failed to ensure that pain management was provided to one of six residents (R) R117 who required such service and was reviewed for pain management. Actual Harm was identified on 5/6/2024 when R117 was exhibiting physical signs and symptoms of pain and distress. Facility staff failed to assess R117's condition and only provided her with Tylenol tablets for pain when she had an active order for a stronger pain medication available. […]

• No harm, potential for more than minimal, widespreadF761Oct 6, 2022

  Based on observations, interviews, and review of the policy titled Storage of Medications, the facility failed to ensure that two of four medication carts were locked and secured when the carts were out of view of the nurse. The census was 151. Findings include: Review of the facility policy titled Storage of Medications dated August 2021 revealed policy interpretation and implementation number 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. […]

• No harm, potential for more than minimal, widespreadF812Oct 6, 2022

  Based on observations, staff interview, and review of the policies titled Food Receiving and Storage and Sanitation, the facility failed to ensure opened food items were properly dated and labeled in the dry food pantry. In addition, the facility failed to ensure the oven and the ventilation hood were cleaned, by due date of 9/22. The census on was 151 Residents. Findings Include: 1. Review of the undated policy titled Food Receiving and Storage revealed policy interpretation and implementation number 6. dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by) date. Such foods will be rotated using a first in - first out system. Number 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by) date. […]

• No harm, potential for more than minimal, patternF759May 10, 2024

  Based on observations, record review, staff interviews, and review of the policy titled Medication Administration, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications were administered as ordered by the physician. A total of 27 medication opportunities were observed, with three errors, for one of five residents (R) R124, for a medication error rate of 11.11%. Findings include: Review of the facility policy titled Medication Administration revised January 2023, Policy Explanation and Compliance Guidelines: Number 11 b. […]

• No harm, potential for more than minimal, patternF656Oct 6, 2022

  Based on observations, record review, interviews, and policy review, the facility failed to follow the care plan related to weekly weights for two residents (R) (R#201 and R#21) and activities of daily living for one resident (R#79). The sample size was 51. Findings include: Review of the undated policy titled Care Plans, Comprehensive Person-Centered revealed policy statement is a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation number 8. The comprehensive, person-centered care plan will: a. includes measurable objectives and timeframes; b. […]