Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Five Towns Premier Rehabilitation & Nursing Ce during CMS and state inspections, most recent first.
Incomplete investigation of an unwitnessed resident fall with injury: A cognitively intact resident with muscle weakness and gait/mobility impairment was found on the floor with head swelling, nasal bleeding, and knee redness after an unwitnessed fall. The incident review lacked a statement from the LPN who reported the fall, and the CNA form was not clearly attributable to a specific CNA because the name was missing and the signature was illegible; later staff interviews did not clarify the event.
Failure to notify designated representative of new antibiotic treatment: A resident with severe cognitive impairment, CKD, HTN, and chronic lung disease developed a cough, was started on amoxicillin-clavulanate for the change in condition, and received the antibiotic as ordered. However, the resident’s designated representative was not documented as being notified of the new treatment until several days later, despite facility policy requiring timely notification of the family or health care agent.
Missed Scheduled Dialysis Due to Communication Failure: A resident ordered for hemodialysis three times weekly did not receive a scheduled treatment because facility staff and dialysis staff failed to coordinate after a planned blood transfusion was cancelled. The resident had diagnoses including sepsis, DM2, and PNA, and the chart showed the dialysis center was not notified that the transfusion was no longer needed, resulting in the missed HD session.
A resident with multiple comorbidities and severe cognitive impairment fell out of bed and was assessed by a nurse, but the incident was not documented, reported to the physician or family, or followed up according to facility policy. As a result, the resident was not monitored for pain or injury, and a fractured femur was only discovered two days later after bruising and pain developed.
A facility failed to accurately document a resident's use of hearing aids in the MDS assessment, despite physician orders and a care plan indicating their use. The resident, who was cognitively intact, was noted to have moderate hearing difficulty, but the MDS incorrectly stated no hearing aid use. The MDS Coordinator admitted the error, and the DON stressed the importance of accurate record review.
A resident with a Stage 4 pressure ulcer did not receive the correct treatment as per physician orders. An LPN failed to apply Clotrimazole cream to the peri-wound and used a collagen dressing without silver, contrary to the order. The facility's policies were not followed, and the product was mislabeled by the pharmacy.
A resident with a Stage 4 pressure ulcer did not receive the correct wound care treatment due to a pharmacy mislabeling error. The prescribed collagen dressing with silver was replaced with a product lacking silver, despite the pharmacy label indicating otherwise. The error was confirmed by nursing staff and acknowledged by the pharmacist.
During a survey, a facility was found to have food safety deficiencies, including storing tuna salad beyond the allowed time and serving egg, potato, and macaroni salads at unsafe temperatures. Staff interviews revealed lapses in monitoring and recording food temperatures, contributing to the deficiency.
A deficiency in infection control was identified when an LPN used normal saline-soaked gauze pads, initially placed on a resident's hip, to cleanse a Stage 4 pressure ulcer. This action violated the facility's aseptic dressing technique policy, which requires maintaining aseptic conditions during wound care. Despite being informed of the breach, the LPN continued the treatment without re-cleansing the wound. Interviews with facility staff confirmed the failure to maintain an aseptic technique.
Incomplete investigation of an unwitnessed resident fall with injury
Penalty
Summary
The facility failed to ensure that an alleged incident involving Resident #6 was thoroughly investigated. Resident #6, who had diagnoses including muscle weakness, gait and mobility abnormality, and depression, was cognitively intact on admission with a BIMS score of 14 and had no recent falls documented. On 11/15/2025, the resident had an unwitnessed fall and was found on the floor on the left side of the bed in a supine position with a pillow under the head, swelling to the forehead and nose, minimal bleeding from both nostrils, and redness to both knees. The resident stated they had used the restroom, tripped while returning to bed, fell, and hit their head. The physician ordered transfer to the hospital for a CT scan of the head. The incident investigation was incomplete and inconsistent. The occurrence report indicated that LPN #1 reported the fall to the charge RN, but no statement was obtained from LPN #1. The CNA question sheet did not identify the CNA by name and had an illegible signature, making it difficult to determine who completed it. The sheet stated the resident was last seen in the room in bed watching television at 07:10 AM before the unwitnessed fall. During later interviews, LPN #1 stated they did not recall the incident, CNA #6 stated they did not remember the incident or the resident, and the charge RN was interviewed regarding the event.
Failure to Notify Designated Representative of New Antibiotic Treatment
Penalty
Summary
The facility failed to ensure that Resident #5’s designated representative was notified when a new treatment was started after a change in condition was identified. Resident #5 was admitted with chronic kidney disease, hypertension, and atelectasis, and the Quarterly MDS documented severe cognitive impairment with a BIMS score of 6, along with active diagnoses of respiratory failure and chronic lung disease. On 08/07/2025, a nursing progress note documented an occasional productive cough with no shortness of breath, and Physician #2 was notified and ordered amoxicillin 875 mg-potassium clavulanate 125 mg for cough. The antibiotic was administered as ordered from 08/07/2025 through 08/14/2025. There was no documented evidence that Resident #5’s designated representative was notified of the change in condition and the new antibiotic treatment until 08/12/2025. The facility policy stated that changes in condition are to be communicated to the physician and other team members, and that the resident’s family or health care agent will be notified about the change in condition. During interviews, the LPN medication nurse stated the charge nurse was responsible for notifying resident representatives and that she did not call the designated representative. The RN charge nurse stated she was responsible for notification and said she forgot to notify the designated representative when the antibiotic order was first received. The DON stated nurses should notify designated representatives in a timely manner and document the notification.
Missed Scheduled Dialysis Due to Communication Failure
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis received treatment as ordered. Resident #3 had diagnoses including sepsis, type 2 diabetes, and pneumonia, had intact cognition with a BIMS score of 15, and was ordered to receive hemodialysis every Monday, Wednesday, and Friday at the facility’s in-house dialysis center. The care plan included monitoring the dialysis access site, communication between nursing staff and the hemodialysis center, and providing a renal diet as ordered. On the scheduled dialysis day, the resident did not receive dialysis because facility staff and dialysis center staff did not communicate effectively about a planned blood transfusion. Nursing documentation showed the resident had been expected to receive a transfusion, but the physician later determined it was not necessary and ordered a repeat CBC instead. The dialysis communication tool documented that the resident was rescheduled for dialysis the next day, and the dialysis director stated the resident missed the treatment because the facility did not notify dialysis staff that the transfusion had been cancelled. The physician, DON, and RN all stated they were not aware the resident had missed the scheduled dialysis treatment.
Failure to Document, Report, and Monitor After Resident Fall Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, chronic kidney disease, diabetes, and major depressive disorder fell out of bed. The Registered Nurse Supervisor assessed the resident and assisted in returning them to bed using a Hoyer lift. However, the nurse failed to document the fall in the electronic medical record, did not complete a facility Occurrence Report, and did not notify the physician or the resident's family as required by facility policy. As a result, the incident was not communicated to the appropriate parties, and the resident was not monitored for pain or injury following the fall. Two days after the fall, staff observed bruising and swelling on the resident's right leg, accompanied by decreased range of motion and pain. The resident was subsequently sent to the hospital, where a fractured right femur was diagnosed. The lack of timely documentation and notification meant that the resident did not receive appropriate follow-up care or monitoring for potential injuries in the immediate aftermath of the fall. Interviews with staff confirmed that the Registered Nurse Supervisor did not report or document the incident at the time, citing being occupied with other duties. The Director of Nursing and Administrator both acknowledged that the nurse failed to follow established policy for reporting and documenting incidents. The deficiency resulted in actual harm to the resident, as the injury was not identified or treated promptly.
Inaccurate MDS Assessment for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with bilateral hearing loss. Specifically, the MDS assessment for a resident, dated 8/17/2024, did not document the use of hearing aids, despite the resident having a physician's order for bilateral hearing aid use and a care plan indicating the use of hearing aids. The resident was cognitively intact with a Brief Interview for Mental Status score of 14, and the assessment noted moderate hearing difficulty but incorrectly stated that the resident did not use hearing aids. Interviews revealed that the MDS Coordinator acknowledged the error, stating that the MDS was coded incorrectly as the resident was using hearing aids during the assessment period. The Director of Nursing Services emphasized that MDS Assessors should review medical records to ensure accurate coding. The MDS Assessor responsible for the error was unavailable for an interview, highlighting a lapse in the facility's assessment process.
Failure to Administer Correct Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident #19, during a recertification survey. The resident, who had a Stage 4 pressure ulcer on the right buttock, did not receive the necessary treatment as per the physician's orders. Specifically, during a wound care observation, the Licensed Practical Nurse (LPN) did not apply the prescribed Clotrimazole cream to the peri-wound area and used a collagen dressing that did not contain silver, contrary to the physician's order. The facility's policies required nurses to follow physician orders and ensure the correct medication and treatment were administered. However, the LPN was unaware of the treatment order for the peri-wound and failed to verify the wound care product's ingredients, which led to the use of an incorrect dressing. The Registered Nurse confirmed that the product used did not contain silver, and the pharmacist acknowledged the mislabeling of the product sent to the facility. Interviews with the Wound Care Registered Nurse and the Director of Nursing Services highlighted that the LPN should have checked the product packaging and ensured compliance with the physician's orders. The Director of Nursing Services emphasized that all treatments should have been administered simultaneously, and the LPN was expected to be aware of the complete treatment plan for the resident's pressure ulcer.
Pharmaceutical Service Deficiency in Wound Care
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident with a Stage 4 pressure ulcer. The resident, who had severely impaired cognitive skills and was dependent on a ventilator, had a physician's order for a collagen wound treatment product containing silver, an antimicrobial agent. However, during a wound care observation, it was discovered that the product used did not contain silver, despite the pharmacy label indicating otherwise. This discrepancy was confirmed by a registered nurse who reviewed the product packaging. The issue arose because the pharmacy supplied a mislabeled product that did not match the physician's order. The pharmacist acknowledged the error but was unsure why the incorrect product was sent. The Director of Nursing Services confirmed the mislabeling and noted that the treatment nurse should have verified the product and informed a supervisor. This oversight resulted in the resident not receiving the prescribed treatment for their pressure ulcer.
Food Safety Deficiency in Kitchen and Dining Services
Penalty
Summary
The facility failed to adhere to professional standards for food safety during a recertification survey. During a kitchen tour, a container of tuna salad dated 11/12/2024 was found in the refrigerator, indicating it was stored beyond the facility's policy of discarding refrigerated foods after 72 hours. Additionally, during a dining observation, it was noted that the temperature of egg salad, potato salad, and macaroni salad served during lunch was above the acceptable standards for safe serving temperatures. The facility's policy requires cold foods to be maintained at or below 41 degrees Fahrenheit, but the recorded temperatures were 68, 65, and 62 degrees Fahrenheit, respectively. Interviews with the dietary staff revealed lapses in monitoring and recording food temperatures. The Dietary Aide stated that they did not take temperatures of cold foods unless they were the main entree, and the Dietary Supervisor confirmed that temperature logs for cold food items were not maintained. The Executive Chef acknowledged that the recorded temperatures were in the danger zone, where bacteria grow most rapidly, making the food unsafe to serve. The Food Service Director confirmed that the facility's practices did not align with their policies, contributing to the deficiency.
Infection Control Breach During Wound Care
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's infection prevention and control program. The incident involved a resident with a Stage 4 pressure ulcer on the right buttock. The resident, who had severely impaired cognitive skills, was observed receiving wound care from an LPN. The LPN placed normal saline-soaked gauze pads directly on the resident's exposed skin on the right hip and then used the same gauze pads to cleanse the pressure ulcer. This action was contrary to the facility's policy on aseptic dressing technique, which requires maintaining aseptic conditions during dressing changes. The facility's policy mandates that a clean barrier should be used to protect equipment from contamination, and all supplies should remain on the tray during wound care. The LPN's actions were observed by a surveyor, who noted the breach in infection control. Despite being informed of the issue, the LPN continued the treatment without re-cleansing the wound. Interviews with the facility's infection preventionist, wound care nurse, and director of nursing services confirmed that the LPN's actions did not maintain an aseptic technique, as the hip is not considered a clean area.
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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 Woodmere
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynbrook Restorative Therapy And Nursing | 2.4 mi | ★★★★★ | 5 | 0 |
| Oceanview Nursing & Rehabilitation Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Haven Manor Health Care Center, Llc | 3.1 mi | ★★★★★ | 16 | 0 |
| West Lawrence Care Center, L L C | 3.1 mi | ★★★★★ | 0 | 0 |
| Queens Nassau Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.