Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 White Oaks Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A CNA failed to follow the care plan and physician's order requiring a two-person assist for transferring a resident with severe cognitive impairment and multiple comorbidities. The CNA transferred the resident alone, resulting in a fractured upper arm. Facility investigation confirmed that the improper transfer technique and lack of adherence to the care plan led to the resident's injury.
Food storage and meal service practices were not maintained according to food safety standards. In the freezer, multiple items were found undated, unlabeled, or in opened packaging, including frozen desserts, vegetables, pizza, roast beef, and other unidentified foods. During lunch service, staff monitored hot foods but did not check cold items such as sandwiches, milk, and yogurt; when temperatures were later taken, several cold items were above the acceptable range.
Improper Bed Blocking Used as a Physical Restraint: A resident with severe cognitive impairment, falls, and mobility assistance needs was intentionally blocked in bed by a CNA using an empty bed on one side and a Geri-chair on the other to stop the resident from getting out of bed. The resident had recently fallen from bed, and the care plan and PT notes identified floor mats and a low bed as the fall-prevention measures, not restricting movement with furniture.
A resident with severe cognitive impairment, MS, and an elopement risk had a Wanderguard ordered on the right lower extremity, but staff did not ensure it remained in place. After the resident previously removed the device, no new interventions were added, and during observation the resident was found without the bracelet while ambulating independently with a cane. Staff were unaware the device was missing, and an LPN had not checked for it during med pass despite the expectation for each-shift checks.
A resident with COPD, CHF, schizophrenia, oxygen therapy, and BiPAP use did not receive pulse oximetry monitoring after nursing staff stopped checking O2 sats when a vital signs order was discontinued. The physician documented COPD follow-up, decreased breath sounds, slight rales, and a goal to keep O2 saturation above 88%, but later stated they did not direct staff to stop monitoring and expected daily O2 sat checks for the resident on oxygen. Staff and the physician gave conflicting accounts, and the medical director stated an order should have been written for ongoing O2 saturation monitoring.
An LPN failed to follow wound care infection control practices for a resident with bilateral heel pressure injuries by not performing hand hygiene between steps, using multiple gloves instead of hand hygiene, and allowing cleansed wounds to touch a dirty pillow without re-cleansing them. In a separate event, a CNA entered a resident’s Contact Isolation room to deliver a lunch tray without gown, gloves, or hand hygiene, despite posted instructions and available PPE.
Nursing staffing sheets were not posted daily and did not include the actual hours worked by licensed and unlicensed nursing staff for each shift. The entrance posting showed an outdated sheet on one day and later sheets contained projected staffing rather than actual shift hours. The Staffing Coordinator, DON, Administrator, and receptionist each described their roles in preparing or posting the sheet, but stated they were not aware the posting had to reflect actual staffing hours.
Facility Assessment did not accurately document RN staffing needs for normal operations, nights, weekends, and emergencies. The assessment listed lower RN ranges for each unit, but the Staffing Coordinator, DON, and Administrator stated the facility actually scheduled at least one RN on duty each shift, including weekends and holidays, and that the lower ranges were intended only for emergency circumstances.
The facility failed to report multiple unwitnessed injuries of unknown origin involving a resident with Dementia and impaired cognition to the New York State Department of Health. The injuries included a laceration requiring hospital treatment and several bruises. The facility's investigations lacked comprehensive statements from involved staff and concluded no abuse or neglect without sufficient evidence.
A resident with Dementia and impaired cognition sustained multiple unwitnessed injuries of unknown origin, including a laceration requiring hospital treatment and several ecchymotic areas. The facility failed to thoroughly investigate these incidents, lacking statements from key staff and consistent documentation. The Risk Manager and other staff acknowledged discrepancies and missing documents in the investigation reports.
A facility failed to develop a Baseline Care Plan within 48 hours for a resident admitted with a Stage 1 Sacral Pressure Ulcer. The resident's condition was not documented in the initial care plan, and appropriate interventions were not included, contrary to the facility's policy and CMS guidelines.
The facility failed to update the Comprehensive Care Plans for two residents, one with pressure ulcers and another with edema, leading to inadequate care. The plans did not reflect the use of a heel off-loading medical surgical shoe and lower leg compression wraps, respectively.
A registered nurse administered a Levothyroxine tablet to a resident from another resident's blister pack due to running out of the medication. The nurse admitted to borrowing the medication despite knowing it was against policy, and the Director of Nursing Services confirmed that borrowing medications is not allowed.
A resident with cognitive impairment and physical limitations was observed with long, dirty fingernails on two occasions. The facility's policy required daily cleaning and trimming of nails, but this was not done, even though staff acknowledged their responsibility for this task.
The facility failed to ensure that two residents with limited range of motion received appropriate treatment, as they were observed multiple times without the physician-ordered hand rolls. Staff were either unaware of the requirement or failed to apply the hand rolls due to being busy or facing difficulties.
A resident with multiple diagnoses was observed with Physician-ordered medication in their room without staff supervision. The resident was not assessed for the ability to safely self-administer the medication, and there was no Physician's order permitting self-administration. Staff confirmed that the medication should have been stored securely and not left unattended.
A resident on anticoagulant therapy was observed with a bruise on the left hand, which a CNA failed to report to the RN as required by facility policy. The resident's care plan mandated regular skin assessments and gentle handling, but the CNA assumed the nurse was already aware and did not report the bruise.
The facility failed to ensure proper medication management and record-keeping. A resident did not receive their prescribed Levothyroxine on time, leading a nurse to borrow the medication from another resident. Additionally, the Controlled Substance Administration Record for another resident was not accurately reconciled, with discrepancies found in the Clonazepam count.
The facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services, leading to residents being served meals on disposable dinnerware due to short staffing in the kitchen. Two residents on Unit 1 North were observed eating breakfast on disposable plates, and during a Resident Council Meeting, all eight residents confirmed that this often occurred on weekends.
Failure to Follow Two-Person Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident with severe cognitive impairment, vascular dementia, a history of stroke, and osteoarthritis. The resident had a physician's order and care plan requiring a two-person assist for all transfers due to their medical condition and mobility limitations. Despite this, the CNA transferred the resident alone from a wheelchair to a bed, using a 'bear hug' technique, which was not in accordance with the established care plan or facility policy. Following the transfer, the resident was found to have a bruise, swelling, and pain in the left upper arm. An X-ray confirmed an acute fracture of the proximal humerus. The CNA admitted during interviews that they performed the transfer alone and did not check the care plan or seek assistance, stating they believed the resident had always required only a one-person assist. The CNA also reported that they did not notice any injury or discomfort during or immediately after the transfer. Facility investigation determined that the CNA's failure to follow the two-person assist order directly contributed to the resident's injury. The incident was identified through review of medical records, staff interviews, and the facility's accident/incident report. The resident's medical history, including frailty and easy bruising, was noted as a factor that increased the risk of injury during improper transfers.
Food Storage and Meal Temperature Monitoring Deficiency
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the kitchen observation, multiple frozen food items in the walk-in freezer were found undated and/or in opened packaging, including tiramisu, broccoli florets, pizza slices, diet pudding, regular pudding, peaches, roast beef, Brussel sprouts, and other unlabeled items that the Registered Dietitian could not identify. Facility staff stated that food removed from original packaging must be labeled and dated, but the observed items were not maintained in that manner. During the lunch meal observation on Unit 2 South, cold food items such as milk, yogurt, sandwiches, juice, and dessert were placed on resident trays, with some items kept in ice and sandwiches placed without ice or another cooling method. Staff were observed taking temperatures of hot foods, but not the cold foods. When the cold items were later checked at the request of the State Agency, temperatures were above the standard range, including sandwiches at 60 degrees Fahrenheit and 59 degrees Fahrenheit, milk at 42.1 degrees Fahrenheit, and yogurt at 50.2 degrees Fahrenheit. Staff interviews confirmed that cold food temperatures were not routinely monitored on the units, and the Administrator stated awareness that food temperatures should be monitored but was not aware that cold food temperatures were not being checked.
Improper Bed Blocking Used as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when Resident #36 was intentionally blocked in bed by staff. On 09/02/2025, the resident was observed sleeping in bed with another empty bed positioned on the right side and a Geri-chair placed on the left side, blocking the resident from getting out of bed. During an interview on 09/05/2025, the assigned CNA acknowledged that they intentionally placed the bed and Geri-chair beside the resident to prevent the resident from getting out of bed. Resident #36 had diagnoses including muscle wasting and atrophy, repeated falls, and generalized anxiety disorder, and the quarterly MDS documented severe cognitive impairment with a BIMS score of 99. The MDS also showed the resident required partial or moderate assistance with bed mobility and transfers and did not have physical restraints or alarms during the assessment period. The care plan for falls/safety included floor mats on each side of the bed, keeping the bed in the lowest position, and referral to rehabilitation services as needed. The record also showed the resident had fallen out of bed on 09/01/2025 and was found on the floor mat with the body and head in bed, without injury. PT screened the resident after the fall and documented no change in range of motion or functional mobility, with floor mats in place and continued monitoring. Staff interviews confirmed the resident had a history of falls and that the intended intervention was floor mats with the bed in the lowest position, not positioning furniture to restrict movement.
Missing Wanderguard and Inadequate Supervision for Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure that a resident at risk for elopement received adequate supervision and assistance devices to prevent accidents. Resident #12 had diagnoses including Multiple Sclerosis, Malnutrition, and Chronic Pain, and a Quarterly MDS documented severe cognitive impairment with a BIMS score of 3. The resident also had a nursing elopement risk evaluation identifying the resident as at risk for elopement and a care plan for elopement/wandering that included use of a Code alert/Wanderguard on the right lower extremity. The record showed that on 08/01/2025 the resident removed the Wanderguard by cutting the strap, the room was searched, and the device was reapplied to the right lower extremity. No new interventions were added to the care plan at that time. A physician’s order directed that the Wanderguard be applied to the right lower extremity each shift, and the treatment administration records reflected staff signatures indicating the device was present each shift. During observation on 09/05/2025, the resident was seen sitting in the day room and ambulating independently with a cane from the room to the day room. The resident did not have the Wanderguard on the right lower extremity, and staff initially were not aware it was missing. A CNA checked and confirmed the resident did not have the Wanderguard on, and the charge nurse later found the device on the bedside table without the strap. Interviews also showed the medication nurse had not checked whether the resident was wearing the Wanderguard during medication administration, despite the expectation that placement be checked each shift.
Failure to Continue Ordered Oxygen Saturation Monitoring
Penalty
Summary
Resident #129 did not receive pulse oximetry monitoring as recommended by the physician in a progress note, even though the resident had diagnoses including COPD, CHF, and schizophrenia, and the resident’s quarterly MDS documented moderate cognitive impairment, oxygen therapy use, and BiPAP use. The resident had current orders for continuous oxygen at 3 liters per minute, head-of-bed elevation to reduce shortness of breath, nebulizer treatments, Advair, heart monitor use, and BiPAP at bedtime for sleep apnea. A prior order for vital signs, including oxygen saturation monitoring, had been discontinued on 09/01/2025. The physician’s 09/01/2025 progress note documented follow-up for COPD, decreased breath sounds bilaterally, slight rales at the bases, and a goal to maintain oxygen saturation above 88%, with BiPAP nightly and as needed for hypoxia. However, nursing staff stopped checking oxygen saturation on 09/01/2025, and there was no associated progress note explaining the change. During interview, the charge nurse stated oxygen saturation checks stopped because the doctor said they no longer had to be done, while the physician stated they did not order or direct that monitoring to stop and said the resident was on oxygen and required oxygen saturation monitoring daily. A nursing progress note later documented that oxygen saturation monitoring was no longer required because the resident remained stable with supplemental oxygen and showed no signs of respiratory distress, but the physician later reiterated that they had not given direction to discontinue monitoring and that oxygen saturation should be checked daily to ensure the resident was not desaturating. The medical director also stated the physician should have written an order for oxygen saturation monitoring to ensure the resident remained above 88%.
Infection Control Failures During Wound Care and Contact Isolation
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections. During wound care for a resident with bilateral heel pressure injuries, an LPN performed the treatment without consistent hand hygiene between steps, used multiple pairs of gloves instead of hand hygiene, and allowed the cleansed heel wounds to contact a dirty pillow surface without placing a protective barrier. The wounds were not re-cleansed after contacting the dirty surface. The resident had severe cognitive impairment and was being treated for a Stage 3 pressure ulcer on the right heel and an unstageable pressure ulcer on the left heel. The wound care observation showed the LPN set up supplies on a clean field and washed hands before starting, but then removed and replaced gloves during the procedure without performing hand hygiene as required by the facility policy. The LPN cleansed the left heel, allowed it to touch the dirty pillow, applied treatment and dressing, and then moved to the right heel without hand hygiene. The same issue occurred with the right heel, which also contacted the dirty pillow after cleansing. The LPN stated they should have had help elevating the resident’s legs, should have used a clean barrier, and should have re-cleansed the wounds after contact with the dirty surface. The wound care RN, the IP LPN, and the DON all stated that hand hygiene should have been performed during the wound care process and that the wounds should have been re-cleansed after contacting the dirty surface. The facility also failed to follow Contact Isolation precautions for a resident with a wound infection caused by Klebsiella pneumoniae. The resident had moderate cognitive impairment, an active MDR organism diagnosis, and a right hip wound infection. A CNA was observed entering the resident’s room to deliver a lunch tray without wearing a gown and gloves and without performing hand hygiene before entering or after exiting the room. The CNA stated they knew PPE was required but did not use it because the PPE was inside the room and they were only handing the tray to the resident’s family member. The room had a posted Contact Isolation sign instructing staff to clean hands before entering and when leaving and to wear gown and gloves before entry. The RN unit manager, IP, and DON stated that hand hygiene was expected before entering and after exiting the room.
Nursing staffing sheet not posted daily with actual shift hours
Penalty
Summary
The facility did not ensure nursing staffing was posted daily and did not include the actual number of licensed and unlicensed staff working hours per shift on the posted staffing sheets. During an observation on 09/02/2025 at 9:28 AM, the staffing sheet displayed in the entrance lobby was dated 08/29/2025 and did not show actual hours worked for the 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM shifts. Later that day at 3:15 PM, the posted sheet was dated 09/02/2025 and included projected staffing for the night shift, but still did not include actual hours worked for any shift. On 09/03/2025 at 9:00 AM, the posted sheet was dated 09/03/2025 and included projected staffing for the evening and night shifts, but again did not contain actual hours worked by licensed and unlicensed nursing staff for each shift. The facility’s Staffing policy, last revised 11/01/2023, addressed providing sufficient licensed and non-licensed personnel on a 24-hour basis but did not include guidance about staffing sheet posting. The facility did not have a policy related to the staffing posting requirement. During interviews, the Staffing Coordinator stated they prepared the staffing sheet in advance using the projected schedule and resident census, sent it to the receptionist for posting, and did not revise it for staffing or census changes. The Staffing Coordinator also stated no one was assigned to revise the posted sheet and was not aware the sheet had to include actual hours worked. The DON and Administrator stated the receptionist posted the sheet daily and the RN supervisor was responsible for revising it as needed, but both stated they were not aware the sheet must include actual licensed and unlicensed nursing staff working hours for each shift. Receptionist #1 stated they posted the sheet daily but did not make changes to it and was unsure why the 08/29/2025 sheet was still displayed on 09/02/2025.
Facility Assessment Did Not Match RN Staffing Needs
Penalty
Summary
The facility did not ensure its Facility Assessment determined and documented the specific nursing staffing needed to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. The facility’s policy stated that the assessment would address staffing needed to provide competent support and care for the resident population every day, including weekends and emergencies, and that it would be reviewed and updated quarterly, annually, or when substantial changes occurred. A review of the Facility Assessment showed that each resident unit was documented as requiring zero (0) to one (1) RN on the day shift, and that during the evening and overnight shifts only unit 1 North required zero (0) to one (1) RN while the other units did not require an RN. However, interviews with the Staffing Coordinator, DON, and Administrator showed the facility actually scheduled one (1) RN on each resident unit during the day shift and always had at least one (1) RN on duty during the evening and overnight shifts, including weekends and holidays. The Administrator stated the lower staffing ranges in the Facility Assessment were intended to represent the bare minimum for emergency circumstances only and were not the staffing levels used for normal day-to-day operations.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported to the New York State Department of Health. This was identified for a resident with a diagnosis of Dementia and impaired cognition, who sustained multiple unwitnessed injuries of unknown origin. Specifically, the resident had a laceration to the right arm requiring hospital treatment, a bruise on the left buttock, and bruises on the left upper inner forearm and right outer arm. The facility failed to report these injuries to the New York State Department of Health as required by their policy. The facility's policy on Abuse Prevention and Reporting mandates that all alleged cases of abuse, neglect, or mistreatment be reported to the Department of Health immediately, but no later than two hours if the alleged violation involves abuse or results in serious bodily injury, or 24 hours if it does not. Despite this, the facility did not report the resident's injuries. The investigation summaries for each incident lacked comprehensive statements from all involved staff members and did not include statements from the staff who initially found the resident with the injuries. Additionally, the facility's investigations concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred, without sufficient evidence to support these conclusions. The Risk Manager, Administrator, and Director of Nursing Services were responsible for reviewing the Accident and Incident reports to determine if further investigation was required and whether the incidents should be reported to the New York State Department of Health. However, they failed to report the incidents involving the resident's injuries of unknown origin. The Director of Nursing Services believed there were known causes that explained how the resident could have sustained those injuries, which led to the decision not to report the incidents. This failure to report is a deficiency in adhering to the facility's policy and regulatory requirements.
Failure to Thoroughly Investigate Injuries of Unknown Origin
Penalty
Summary
The facility did not ensure that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown source. This was identified for one resident with a diagnosis of Dementia and impaired cognition who sustained multiple unwitnessed injuries of unknown origin. Specifically, the resident had a laceration to the right arm requiring hospital treatment, and multiple ecchymotic areas on different occasions. The facility failed to thoroughly investigate these incidents to identify the root cause and rule out abuse, neglect, or mistreatment. The facility's policy on Abuse Prevention and Reporting required the nursing supervisor to begin an investigation upon identification of an incident, obtain all necessary statements, and report all allegations to the Administrator. However, the investigation into the resident's injuries lacked statements from key staff members and did not include consistent or accurate documentation. For instance, the Accident and Incident report for the laceration on the resident's right arm was not signed by the nurse who initiated it and did not identify the Certified Nurse Aide who initially reported the injury. Additionally, there were discrepancies in the statements provided by staff members, and some staff were not interviewed or asked to write statements. Further incidents involving ecchymotic areas on the resident's left buttock and arms were also inadequately investigated. The facility did not obtain statements from staff on previous shifts to determine the root cause of these injuries. The Risk Manager acknowledged that there were missing documents and inaccurate dates in the investigation reports. The Administrator and the Director of Nursing Services admitted that there was room for improvement in how investigations were conducted, indicating a systemic issue in the facility's approach to handling and documenting incidents of unknown origin.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility did not ensure that a Baseline Care Plan for each resident was developed within 48 hours of admission, as required by their policy and Centers for Medicare & Medicaid Services guidelines. This deficiency was identified for a resident admitted with Alzheimer's Disease, Parkinson's Disease, and a Stage 1 Sacral Pressure Ulcer. The resident's Admission Nursing Evaluation documented the presence of a Stage 1 Sacral Pressure Ulcer, but the Baseline Care Plan created did not include this information or any interventions for skin breakdown. The resident's condition was later assessed as a Stage 2 Pressure Ulcer, and a Comprehensive Care Plan was developed, but this was not within the required 48-hour window from admission. Interviews with the unit Charge Nurse and the Director of Nursing Services confirmed that the Baseline Care Plan should have included the resident's Pressure Ulcer and appropriate interventions. The failure to develop a complete Baseline Care Plan within the required timeframe was a clear deviation from the facility's policy and professional standards of quality care. This oversight was identified during the Recertification Survey, highlighting a lapse in the facility's adherence to care planning protocols for newly admitted residents with immediate needs.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility did not ensure that each resident's Comprehensive Care Plan was reviewed and revised to reflect their current needs. This deficiency was identified for two residents: one with pressure ulcers and another with edema. Specifically, Resident #78's Comprehensive Care Plan was not updated to reflect the use of a heel off-loading medical surgical shoe or offloading the heels, and Resident #171's Comprehensive Care Plan was not updated to reflect the use of lower leg compression wraps to treat bilateral lower leg edema. Resident #78 was admitted with Alzheimer's Disease, Parkinson's Disease, and a Stage 1 Sacral Pressure Ulcer. Despite the presence of a blister on the right heel and recommendations for offloading the heels, the Comprehensive Care Plan was not updated to include these interventions. Interviews with various staff members revealed a lack of documentation and communication regarding the use of the heel off-loading medical surgical shoe, leading to a delay in appropriate care. Resident #171, who had Multiple Rib Fractures, Vascular Dementia, and Hypertension, was observed with swollen lower legs and no compression wraps, despite a physician's order for their use. The Comprehensive Care Plan was not updated to include the physician-ordered compression wraps. Interviews with staff indicated that the care plans should have been updated when the compression wraps were ordered, but this was not done, resulting in inadequate care for the resident's edema.
Medication Administration Deficiency
Penalty
Summary
The facility did not ensure that services provided or arranged by the facility met professional standards of care. During a medication pass observation, a registered nurse administered a Levothyroxine 50 microgram tablet to Resident #169 from a blister pack labeled for another resident, Resident #49. This occurred because the nurse was unable to locate the medication for Resident #169 and decided to borrow it from another resident's supply. The nurse acknowledged that the medication should have been reordered when there were 3 to 4 pills left in the blister pack and admitted to borrowing the medication despite knowing it was against policy. Interviews with the nursing staff and the Director of Nursing Services confirmed that borrowing medication from one resident to administer to another is not allowed. The Director of Nursing Services emphasized that there should not be any occasion where a resident's medication runs out and that there is no policy permitting the borrowing of medications. The incident highlighted a failure in adhering to the facility's Medication Administration policy and procedure, which requires medications to be administered accurately and timely by comparing the medication administration record against the prescription label.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #56 was observed on two separate occasions with long fingernails and a brown substance under the nails of the left hand. The resident's right-hand fingernails were resting on the resident's palm. The resident had a right-hand contracture and generalized osteoarthritis, requiring moderate assistance for personal hygiene and extensive assistance for all activities of daily living. The facility's policy required daily cleaning and regular trimming of nails, which was not adhered to in this case. Interviews with staff revealed that the Certified Nursing Assistants (CNAs) were responsible for trimming and cleaning the resident's nails, particularly on shower days. However, the regularly assigned CNA was on vacation, and the substitute CNA did not perform the necessary nail care. Both the unit manager and the Director of Nursing Services confirmed that there was no excuse for the resident's nails not being cleaned and trimmed, indicating a lapse in the facility's adherence to its own policies and procedures for nail care.
Failure to Apply Physician-Ordered Hand Rolls
Penalty
Summary
The facility did not ensure that residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This deficiency was identified for two residents who had physician orders for hand rolls to be worn at all times. On multiple occasions, these residents were observed without the physician-ordered hand rolls, indicating a failure to follow medical orders and facility policies. Specifically, Resident #56 and Resident #36 were not wearing their hand rolls during several observations, despite having orders for them to be worn continuously except during nursing care, hygiene, and skin checks. Resident #56, who had a right-hand contracture and generalized osteoarthritis, was observed multiple times without the required hand roll. Interviews with staff revealed that some were unaware of the hand roll requirement, and others admitted to forgetting to apply it due to being busy. The resident's care plan and physician's orders clearly documented the need for the hand roll to prevent skin breakdown and manage the contracture, but these were not consistently followed. Similarly, Resident #36, who had vascular dementia and a right-hand contracture, was also observed without the hand roll on multiple occasions. Staff interviews indicated that while some staff were aware of the requirement, they faced difficulties in applying the hand roll, and these issues were not adequately communicated or addressed. The failure to apply the hand roll as ordered by the physician was acknowledged by various staff members, including the unit manager and the director of nursing services, who confirmed that the hand roll should have been in place as per the physician's orders.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility did not ensure that Resident #167's environment remained free of accident hazards, specifically regarding the self-administration of medications. Resident #167, who has diagnoses including Chronic Kidney Failure, Cirrhosis of the Liver, and Hypokalemia, was observed multiple times with Physician-ordered Ammonium Lactate 12% lotion in their room without staff supervision. The resident was not assessed for the ability to safely self-administer the medication, and there was no Physician's order permitting self-administration. Facility policy requires that medications be secured and not left unattended, and that residents be evaluated and have a Physician's order to self-administer medications. Interviews with the resident and staff revealed that the resident sometimes applied the lotion themselves, despite not being able to reach their feet consistently and not having an order to self-administer. The lotion was intended for application to the resident's feet twice daily by a nurse, but it was found on the over-bed table in the resident's room. Staff confirmed that the resident had not been evaluated for self-administration and that the lotion should have been stored in the treatment cart. The Director of Nursing Services and the Pharmacist both emphasized that the lotion should not be left at the bedside and that improper application could cause skin irritation and other complications.
Failure to Report Change in Skin Condition
Penalty
Summary
The facility did not ensure that all nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs. This deficiency was identified for a resident who was observed with a bruise on the back of the left hand. The Certified Nursing Assistant (CNA) who noticed the bruise did not report it to the Registered Nurse (RN) until the Surveyor identified it. The facility's policy requires all nursing staff to report any changes in residents' skin conditions immediately, but this protocol was not followed in this instance. The resident involved had diagnoses including Diabetes Mellitus and Hypertension and was on anticoagulant therapy, which increases the risk of bruising. The resident was cognitively intact and self-reported that the bruise occurred when their hand hit a door frame while propelling their wheelchair. Despite the facility's policy and the resident's care plan requiring regular skin assessments and gentle handling, the CNA failed to report the bruise, assuming the nurse was already aware. This lapse in communication and protocol adherence was confirmed through staff interviews and record reviews.
Medication Management and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident. Specifically, Resident #169 had a physician's order for Levothyroxine 50 micrograms to be administered daily at 6:00 AM. During a medication pass observation, the medication was not available, and the nurse borrowed the medication from another resident's blister pack. The nurse acknowledged that the medication should have been reordered when there were 3 to 4 pills left and admitted to borrowing medication despite knowing it was against policy. The Director of Nursing Services confirmed that borrowing medication is not allowed and that there should be no occasion where a resident's medication runs out. Additionally, the facility did not ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. For Resident #12, the Controlled Substance Administration Record for Clonazepam was not reconciled accurately. The record documented 12 tablets remaining, but only 11 tablets were found in the blister pack. The nurse responsible admitted to administering the medication but failing to update the record immediately. The Director of Nursing Services stated that nurses are expected to sign off on the Controlled Substance Administration Record and Medication Administration Record when administering narcotic medications. These deficiencies were identified during the Recertification Survey and involved both the improper handling of medication for Resident #169 and the inaccurate reconciliation of controlled substances for Resident #12. The facility's policies and procedures were not followed, leading to these lapses in medication management and record-keeping.
Insufficient Support Personnel in Food and Nutrition Services
Penalty
Summary
The facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services. This deficiency was identified during the Recertification Survey when it was observed that residents were served meals on disposable plates, cups, and bowls due to short staffing in the kitchen. Specifically, two residents on Unit 1 North were observed eating their breakfast on disposable dinnerware, and during a Resident Council Meeting, all eight residents in attendance confirmed that they often received meals on disposable items during weekends because of kitchen staffing shortages. Resident #107, who has severe cognitive impairment due to Alzheimer's Disease, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease, was observed with a breakfast tray containing disposable dinnerware. Similarly, Resident #171, who has severely impaired cognition due to Multiple Rib Fractures, Vascular Dementia, and Hypertension, was also observed with a breakfast tray on disposable dinnerware. Resident #171 expressed a dislike for eating meals using disposable dishes but could not recall how often this occurred. Interviews with the Food Service Director, Dietary Aide, and Cook revealed that the use of disposable dinnerware was a result of being short-staffed, particularly on weekends. The Food Service Director acknowledged that disposable dinnerware should only be used in extenuating circumstances, but due to staffing challenges, it was sometimes necessary to use them to ensure timely meal service. The Administrator was aware of the staffing issues and the use of disposable dinnerware, stating that efforts were made to offer overtime and recruit additional staff, but these measures were not always successful in covering shifts.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 713 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Excel At Woodbury For Rehabilitation And Nursing, | 0.1 mi | ★★★★★ | 0 | 0 |
| Woodbury Heights Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Huntington Hills Center For Health And Rehabilitat | 3.2 mi | ★★★★★ | 0 | 0 |
| Central Island Healthcare | 3.2 mi | ★★★★★ | 0 | 0 |
| Apex Rehabilitation & Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
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