Westbury Center of Mcdonough for Nursing & Healing

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jan 24, 2026

  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. […]

• Immediate jeopardy, patternF835Jan 24, 2026

  Based on interviews, record review, review of the Administrator's Job Description, and review of the facility policy titled, Abuse, Neglect and Exploitation, the Administration failed to provide protective oversight of the facility resident's to prevent the sexual assault against Resident (R) (R1) by the male Environmental Service (EVS) Housekeeper EE and failed to identify the EVS entering and remaining in resident rooms (R6) at unusual times, with no cleaning supplies, or housekeeping carts making them feel uncomfortable and afraid. Specifically, the facility Administrator failed to conduct an unbiased investigation and utilized leading questions towards the resident, implying the resident consented to sexual contact with the EVS Housekeeper EE. […]

• Actual harm, isolatedF600Jun 27, 2025

  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. […]

• Actual harm, isolatedF580Mar 15, 2022

  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. […]

• Actual harm, isolatedF600Mar 15, 2022

  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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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. […]