Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Excel At Woodbury For Rehabilitation And Nursing, during CMS and state inspections, most recent first.
The facility did not develop comprehensive, person-centered care plans for two residents with identified needs. One resident had a scalp lesion noted as possible melanoma, multiple scabs, and a habit of picking at them, but the record lacked a complete care plan addressing the lesion and monitoring needs. Another resident had lymphedema with orders for Ace wraps/compression stockings to both lower legs, but no care plan was in place for the edema or compression therapy until later in the review.
Unsecured medications were found in a resident's room when surveyors observed a labeled tube of Lidocaine ointment and two unlabeled bottles of glucose tablets on an overbed table in a half-opened container, with no nursing staff nearby. The resident had DM2, COPD, CKD, intact cognition, an indwelling catheter, and no order for the glucose tablets or assessment for self-administration; the Lidocaine order had already been discontinued.
A resident with metabolic encephalopathy, dementia, and dysphagia had an Annual MDS with a BIMS score showing moderate cognitive impairment, but the assessment was completed well past the required 14-day ARD timeframe. Surveyors found the MDS Coordinator may have entered the wrong completion date, while the DON and Administrator were not familiar with the timing requirements and were unaware the assessment was late.
Late and Unverified MDS Transmissions: Surveyors found that a resident with metabolic encephalopathy, dementia, and dysphagia had multiple MDS assessments that were not transmitted to CMS within the required timeframe, including one quarterly assessment sent late, one annual assessment sent significantly late, and one significant change assessment with no documented transmission. The MDS Coordinator reported technical difficulties and said transmissions were not being verified, while the DON and Administrator were not familiar with the required timeframe.
The facility failed to ensure a comprehensive care plan for a resident who had a physician's order for a hip abduction flexion contracture cushion. The resident was observed without the cushion on two occasions, and staff did not notify the appropriate personnel about the resident's refusal to use the device, leading to a deficiency.
A facility failed to ensure that medication labels matched physician orders for a resident with multiple diagnoses. During a medication pass observation, discrepancies were found in the labels for Allopurinol and Torsemide. The LPN acknowledged the issue but had not reported it to the supervisor. The RN Supervisor and DON were also interviewed, revealing gaps in the facility's policy and practice regarding medication labeling.
The facility failed to protect a resident from abuse when one resident with a history of disruptive behavior was punched in the face by another resident with severe cognitive impairment. Despite behavior care plans and interventions, the incident resulted in physical harm to the resident.
Failure to Develop Comprehensive Care Plans for Skin Lesions and Lymphedema
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents with identified skin and edema-related needs. One resident was admitted with diagnoses including cerebrovascular accident, colon cancer, and muscle wasting, had a BIMS score of 11, and was noted on admission to have a scabbed area at the top of the head. The physician’s admission note listed possible melanoma in the resident’s history/current diagnoses, but the medical record did not identify the lesion location, and there was no comprehensive care plan for the scalp lesions, scabs, or possible melanoma at the time of the survey review. During the survey, the resident was observed with a dry dressing on the head and stated having many scabs on the head and picking at them, and that a dermatologist had previously diagnosed skin cancer. Staff stated they did not know who applied the dressing and acknowledged there was no current order for it and no care plan for the head lesions. A physician later ordered a dry protective dressing for the right parietal scalp and a dermatology consult, and a care plan was added for skin integrity with a dry scab on the scalp; however, the care plan did not identify the possible melanoma, the multiple scabs, or the resident’s picking behavior. Staff and the physician also stated they were unsure of the lesion location until clarified later. A second resident had diagnoses including lymphedema, asthma, and anemia, with a BIMS score of 15 and an active MDS diagnosis of lymphedema. The resident had a physician order for an Ace wrap to both lower legs daily for lymphedema and was observed wearing compression stockings on both lower legs, stating they always needed them. The record did not contain a care plan for lymphedema or for the Ace wrap/compression stocking use until later in the survey review, and nursing leadership acknowledged that a care plan with individualized goals and interventions should have been developed for the resident’s lymphedema and compression therapy.
Unsecured Medications Found in Resident Room
Penalty
Summary
Drugs and biologicals were not stored in a locked compartment for one resident reviewed for accidents. During the recertification survey, Resident #7 was observed in bed with an overbed table in front of them. On the table was a labeled tube of Lidocaine 5 percent ointment and, in a transparent half-opened plastic container, two unlabeled bottles of glucose 4-gram tablets. No nursing staff were in the vicinity of the room at the time of the observation. Resident #7 stated the Lidocaine ointment was being applied by nurses to their back with each incontinence change and that the glucose tablets had been brought from home and had never been used at the facility. Resident #7 had diagnoses including Type 2 diabetes, COPD, and CKD, and the quarterly MDS documented intact cognition with a BIMS score of 15. The record also showed a scheduled pain medication regimen, an indwelling catheter, and care plan interventions for diabetes and pain. The EMR showed no order for glucose 4-gram tablets and no assessment for self-administration of medications. The Lidocaine 5 percent ointment order had been discontinued on 5/16/2025, yet it was still found in the resident's room during the survey.
Late Completion of Annual MDS Assessment
Penalty
Summary
The facility did not ensure that all comprehensive resident assessments were completed within the required timeframe under the LTC Facility Resident Assessment Instrument 3.0 User’s Manual. During the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, surveyors found that one of six residents reviewed for the Resident Assessment Task had an Annual MDS assessment that was not completed by the required deadline. The facility policy titled Minimum Data Set 3.0 stated that all MDS assessments must follow CMS and NYSDOH guidelines and that each department must complete assigned responsibilities no later than 14 days from the ARD. Resident #44 was admitted with diagnoses including metabolic encephalopathy, dementia, and dysphagia, and the Annual MDS documented a BIMS score of 11, indicating moderate cognitive impairment. The Annual MDS had an ARD of 10/3/2024 but was not completed until 11/13/2024, which was 27 days after the completion due date of 10/17/2024. During interviews, the MDS Coordinator stated they were responsible for timely completion and said the assessment should have been completed by 10/17/2024, but may have selected the wrong completion date and did not realize the mistake. The DON stated they were not familiar with the timeframe requirements, and the Administrator also stated they were not familiar with the timeframe requirements and was not aware the assessment had not been completed on time.
Late and Unverified MDS Transmissions
Penalty
Summary
The facility did not ensure that completed MDS assessments were electronically transmitted to CMS within 14 days of assessment completion. During the recertification survey, surveyors identified this issue for one resident reviewed for the Resident Assessment Task. The resident had diagnoses including metabolic encephalopathy, dementia, and dysphagia, and a BIMS score of 7 on the quarterly MDS, indicating moderate cognitive impairment. Record review showed the resident’s quarterly MDS completed on 6/6/2024 was transmitted on 6/24/2024, 4 days after the due date of 6/20/2024. The annual MDS completed on 11/13/2024 was transmitted on 12/27/2024, 30 days after the due date of 11/27/2024. The significant change in status MDS completed on 3/14/2025 had no documented evidence of transmission to CMS within 14 days. The MDS Coordinator stated assessments should be transmitted within 14 days of completion, but also stated there were technical difficulties, changes to the RAI process in October 2024, and that they did not verify whether transmissions were timely and successful because the electronic program did not issue alerts. The DON and Administrator stated they were not familiar with the transmission timeframe requirements.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility did not ensure that a comprehensive person-centered care plan was implemented for Resident #16, who had a physician's order for a hip abduction flexion contracture cushion to be worn at all times. Observations on two separate occasions revealed that the resident was in bed without the required cushion. The facility's policy mandates that nursing staff ensure the wearing schedule for assistive devices is followed and that any adverse reactions are reported to the Occupational or Physical Therapist. However, the resident was found without the cushion, and the staff failed to notify the appropriate personnel about the resident's refusal to use the device. Certified Nursing Assistant #2 admitted to finding the cushion on the floor and placing it in the resident's closet without informing anyone. The Unit Manager and the Director of Nursing Services were unaware of the resident's refusal to use the cushion until much later. The Physical Therapist confirmed that the cushion was necessary to prevent the resident's hips from rotating and legs from contracting. The failure to follow the care plan and notify the relevant departments led to the deficiency identified during the survey.
Medication Labeling Discrepancy
Penalty
Summary
The facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This deficiency was identified during a medication pass observation for a resident with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. The labels on the medication blister packs for Allopurinol and Torsemide did not match the physician's orders. Specifically, the Allopurinol blister pack label indicated a dosage of 100 milligrams every 12 hours, while the physician's order was for 200 milligrams once daily. Similarly, the Torsemide blister pack label indicated a dosage of 20 milligrams twice daily, while the physician's order was for 20 milligrams once daily. The Licensed Practical Nurse acknowledged the discrepancy but had not yet reported it to the supervisor at the time of the observation. Further investigation revealed that the facility's policy required the nurse to compare the physician's orders against the medication administration record and prescription label. The Registered Nurse Supervisor stated that the pharmacy is supposed to send a new blister pack when there is an order change, and if not, the facility staff should follow up with the pharmacy. However, the facility had just received stickers to put on the medication label to indicate changes in the physician's orders, which was a new practice for the staff. The Director of Nursing Services was unsure of the facility's policy regarding discrepancies between physician orders and medication labels but believed that nurses should either label the medication to refer to the medication administration record or contact the pharmacy to rectify the discrepancy.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility did not ensure resident rights to be free from abuse, as evidenced by an incident involving two residents. Resident #311, who had a history of verbally disruptive and intrusive behavior, was transferred to a new unit after a verbal altercation with another resident. Despite the transfer, Resident #311 continued to exhibit disruptive behaviors, including paranoia, agitation, and incessant speaking. On one occasion, Resident #310 punched Resident #311 in the face after Resident #311 used foul language toward them, resulting in a three-centimeter linear scratch to the right face and an open area to the right upper ear. Resident #310 had a history of Anxiety Disorder, Depression, and Psychotic Disorder, with a severely impaired cognition score. Despite being calm and cooperative most of the time, Resident #310 had a history of hallucinations and was on antipsychotic medication. The facility's behavior care plan for Resident #310 included interventions to keep them away from other residents exhibiting behavioral symptoms and to engage them in varied activities. However, the medical record lacked documented evidence of an altercation between Resident #310 and Resident #311 prior to the incident on 7/3/2023. The incident was reported by Certified Nurse Aide #7, who witnessed the altercation and separated the residents. The Director of Nursing Services initially documented that the altercation was not abuse but later corrected this in the report to the New York State Department of Health, indicating that the incident resulted in abuse for Resident #311. Interviews with staff confirmed that Resident #311 had a history of behavioral issues and was difficult to redirect, while Resident #310 admitted to punching Resident #311 because of the foul language used toward them.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Woodbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Oaks Rehabilitation And Nursing Center | 0.1 mi | ★★★★★ | 10 | 0 |
| Woodbury Heights Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Central Island Healthcare | 3.2 mi | ★★★★★ | 0 | 0 |
| Huntington Hills Center For Health And Rehabilitat | 3.2 mi | ★★★★★ | 0 | 0 |
| Apex Rehabilitation & Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
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