Westbury Center Of Conyers For Nursing And Healing
Inspection Findings
F-Tag F0558
F 0558
during Resident R7 nighttime tube feeding infusion, and every 30-minute staff checks during the day, until a suitable call device was obtained for Resident R7 to use.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westbury Center of Conyers for Nursing and Healing
1420 Milstead Road Conyers, GA 30012
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0628
F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
provide the residents with a bed hold policy. She stated that it is not documented anywhere, but it was just known to be provided. In an interview on 8/28/2025 at 2:40 pm, the Administrator revealed that the nurse was responsible for providing the residents with the bed hold policy upon transfer to the hospital, and the business office documented a bed hold in the billing. The Administrator was unable to locate proof that a written bed hold notice was provided to Resident R4 or the resident representative for the hospital transfers dated 6/5/2025 and 6/30/2025. She stated that her expectation was for the nursing staff to provide the bed-hold policy to residents upon transfer to the hospital, and for it to be documented in the resident's record.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westbury Center of Conyers for Nursing and Healing
1420 Milstead Road Conyers, GA 30012
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0759
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff and resident interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the medication error rate was less than 5 percent. The medication error rate was 7.69 percent, with two errors from 26 opportunities for two of four residents (R) (Resident R89 and Resident R77) observed for medication administration. This deficient practice had the potential to place Resident R89 and Resident R77 at risk of adverse effects or a lack of desired effects from the medications. Findings include:Review of the facility's policy titled Medication Administration, revised 4/2025, revealed the Policy section stated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice,
in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section included, . 10. Ensure that the six rights of medication administration are followed: a. right resident, b. right drug, c. right dosage, d. right route, e. right time, f. right documentation. 17. Administer medications as ordered in accordance with manufacturer specifications. 1. Review of the electronic medical record (EMR) revealed Resident R89 was admitted to the facility on [DATE REDACTED] and diagnoses included, but were not limited to, hyperkalemia, acute kidney failure, and encephalopathy.Review of the Quarterly Minimum Data Set (MDS) assessment for Resident R89, dated 6/5/2025, revealed Section K (Swallowing/Nutritional Status) revealed no swallowing disorder.Review of the Physician's Orders for Resident R89 included an order dated 10/28/2023 for atorvastatin calcium oral tablet (a medication used to lower cholesterol) 40 milligrams (mg) daily. Further
review revealed an order dated 12/5/2023 of May alter medication by crushing, opening capsules, and administering with food/liquid unless contraindicated.Observation of medication administration on 8/27/2025 at 8:12 am with Licensed Practical Nurse (LPN) PP revealed LPN prepared, crushed, and administered atorvastatin calcium oral tablet 40 mg to Resident R89.In an interview on 8/27/2025 at 8:12 am, LPN PP confirmed she crushed the atorvastatin oral tablet and administered it to Resident R89. She further confirmed the medication should not be crushed. In an interview on 8/27/2025 at 2:54 pm, the Registered Pharmacist (RPh) stated that atorvastatin calcium tablets should not be crushed.In an interview on 8/28/2025 at 9:10 am, the Director of Nursing (DON) confirmed that medications were to be crushed according to policy, and nurses should follow the list on each medication cart for reference. 2. Review of the EMR revealed Resident R77 was admitted to the facility on [DATE REDACTED] and diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral vascular accident, dysarthria, anarthria, and muscle weakness.Review of
the Physician's Orders for Resident R77 revealed an order dated 11/18/2022 for MiraLax powder 17 grams per scoop, one scoop per day for constipation.Observation of medication administration on 8/27/2025 at 8:48 am with LPN AA revealed LPN AA reviewed the physician's orders and prepared and administered the two scoops of polyethylene glycol [generic medication for MiraLax] to Resident R77.In an interview on 8/27/2025 at 9:00 am, LPN AA confirmed Resident R77 should have received one scoop of polyethylene glycol, and he administered two scoops of polyethylene glycol powder because the resident asked for a second scoop. The LPN confirmed he should have given Resident R77 one polyethylene glycol scoop of powder as ordered. In an interview
on 8/28/2025 at 9:00 am, the Director of Nursing (DON) stated that there was no exception for not following
the doctor's order. The DON stated that expectations for medication change require contacting the provider and obtaining approval prior to administering the medication.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
WESTBURY CENTER OF CONYERS FOR NURSING AND HEALING in CONYERS, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CONYERS, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTBURY CENTER OF CONYERS FOR NURSING AND HEALING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.