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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodbury Heights Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Residents were served meals on disposable plates and utensils due to a broken dishwasher, affecting all nine units. The issue persisted since January 2024, with residents expressing dissatisfaction during a council meeting. The Dietary Supervisor and Administrator acknowledged the problem, citing failed contractor agreements and financial concerns as reasons for the delay in repairs.
The facility failed to monitor cold food temperatures in the Woodcrest One unit, serving food at 50-60°F instead of the required 41°F or below. The Dietary Aide did not take cold food temperatures, and the Registered Dietitian confirmed non-compliance with safety standards. The Food Service Director emphasized the importance of measuring both hot and cold food temperatures to prevent bacterial growth.
The facility failed to maintain its dishwashing machine in safe operating condition, as it has been inoperable since January 2024. Despite receiving a repair quote and approval, delays in parts and hesitancy from ownership due to potential closure or sale plans led to continued non-functionality. The current Food Service Director has been working on obtaining proposals for new equipment.
A resident with intact cognition and respiratory issues was self-administering a nasal spray without an assessment or physician's order. Nurses allowed the resident to self-administer and signed the EMAR, while the DON acknowledged the need for an assessment and physician's order.
A resident's room in a LTC facility was found to have a ripped and stained privacy curtain, indicating a failure to maintain a homelike environment. Despite staff awareness, the issue was not communicated to housekeeping, leading to the deficiency.
A facility failed to accurately document a resident's comfort care status in the MDS assessment. Despite a physician's order for Comfort Measures Only, the MDS inaccurately indicated no comfort care was provided. Staff interviews confirmed the error, highlighting a lapse in following the facility's RAI process policy.
A resident with a drug-resistant Pseudomonas infection was placed on contact precautions, but the facility failed to develop a Comprehensive Care Plan (CCP) to address these precautions until several months later. Interviews with staff revealed confusion over responsibility for care plan development, leading to the oversight.
An LPN on the Woodcrest 2 unit pre-poured medications without proper labeling and attempted to administer them to the wrong resident, who had already received their morning medications. The LPN failed to verify the resident's identity, contrary to the facility's policy requiring the use of two patient identifiers before medication administration.
A resident with multiple pressure ulcers did not receive appropriate care due to a malfunctioning air mattress set incorrectly for their weight. Despite policies requiring interdisciplinary care, staff failed to adjust or monitor the mattress settings, leading to a deficiency in treatment and services.
An unsecured oxygen E-Cylinder tank was found in a resident's room, contrary to facility policy requiring tanks to be secured. The resident, with severe cognitive impairment, had no current oxygen order. Staff interviews revealed a lack of awareness and adherence to safety protocols, despite the facility having sufficient nebulizer machines.
A survey revealed deficiencies in medication management at an LTC facility, including inaccurate records of controlled substances for two residents and improper storage of a discontinued medication. An LPN attempted to administer pre-poured medications to the wrong resident, failing to follow the facility's medication administration policy. Interviews indicated a lack of adherence to procedures for handling controlled substances.
A survey found that a medication refrigerator in a nursing unit was at 60°F, above the recommended 36-46°F for insulin and Trulicity pens. The temperature was not consistently monitored, and staff were unaware of the correct range, violating facility policy.
A resident in the facility did not receive a timely Lipid Profile test, which was ordered in response to a medication review. The test was not communicated to the laboratory due to a two-step ordering system that was not properly followed. The resident, with diagnoses including dementia and diabetes, was on Quetiapine, necessitating regular lipid monitoring. Despite being ordered, the test was not performed, as revealed during a recertification survey.
A resident with severe cognitive impairment and a history of sepsis and pneumonia was observed receiving oxygen therapy as per physician's orders, but the facility failed to document this in the Treatment Administration Record. Interviews with nursing staff revealed a lack of adherence to documentation policies, which was confirmed by the DON.
A resident reported that their bank card was used by an LPN to withdraw $1,000 without authorization. The resident initially gave the card to the LPN to withdraw $800 to repay a debt, but later discovered an additional $200 was withdrawn. Despite the resident's refusal to press charges, the facility terminated the LPN for violating policies on abuse prevention and non-fraternization.
A resident in a LTC facility experienced respiratory distress and was ordered to be transferred to the hospital by a Nurse Practitioner. However, the RN on duty called a non-emergency ambulance, causing a significant delay. The resident, who was ventilator-dependent, died from cardiorespiratory arrest before emergency services arrived. The facility lacked a clear policy on when to contact emergency services, contributing to the delay and subsequent harm.
A resident with Chronic Obstructive Pulmonary Disease (COPD) and a history of unsafe smoking sustained a facial burn while smoking unsupervised with supplemental oxygen. The facility's smoking policy lacked specific guidelines on supervision and monitoring, and there were gaps in staff monitoring and addressing the resident's smoking behavior. The resident's ability to move independently and intact cognition, combined with the facility's failure to reassess or educate on safe smoking practices, contributed to the incident.
The QAPI committee failed to monitor interventions and implement an appropriate plan of action for smoking noncompliance, resulting in regulatory non-compliance. Despite documented interventions, the facility did not provide evidence of follow-through, and smoking noncompliance was not addressed in subsequent QAPI meetings.
A resident reported that a CNA handled them roughly during care, but the incident was not reported to the New York State Department of Health within the required 24-hour timeframe. Despite the facility's policies, the incident was only reported several days later, leading to the identification of this deficiency.
Residents Served Meals on Disposable Ware Due to Broken Dishwasher
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the use of disposable plates and utensils during meal times across all nine units. This issue was observed during the dining task observations on 10/16/2024 and 10/17/2024, where residents were served breakfast and lunch on disposable Styrofoam plates with disposable utensils. The Dietary Supervisor confirmed that this practice was due to a non-functioning dishwashing machine, which had been out of order since January 2024. The Administrator acknowledged awareness of the residents' dissatisfaction and attributed the delay in addressing the issue to failed contractor agreements and financial concerns related to potential facility closure or sale. During a resident council meeting, seven residents expressed dissatisfaction with the use of disposable dining ware, citing it diminished their meal experience. Resident #267, the council president, and Resident #5, a regular attendee, both confirmed that the issue had been repeatedly communicated to the facility's administration. Resident #267, who is cognitively intact, emphasized the negative impact of using Styrofoam plates on the quality of meals. Similarly, Resident #5, also cognitively intact, highlighted the poor quality of plastic utensils, which hindered their ability to enjoy meals. These concerns were documented in the residents' interviews and the facility's failure to address them contributed to the deficiency.
Failure to Monitor Cold Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served in accordance with professional standards for food service safety during a Recertification Survey. This deficiency was identified in the Woodcrest One unit, where the facility did not monitor the temperature of cold food items served to residents during a lunch meal observation. The cold food temperatures were found to be between 50-60 degrees Fahrenheit, which is above the required standard of 41 degrees Fahrenheit or below. The facility's policy mandates that cold food temperatures be taken and recorded for each meal to ensure they remain below 41 degrees Fahrenheit during portioning, transporting, and delivery. During the lunch meal observation, it was noted that the cold food temperature was not documented on the temperature log, and the Dietary Aide did not take the temperature of cold food items, only hot food items. The Registered Dietitian later measured the temperatures of a cheese sandwich and chocolate pudding, finding them to be 60.7 and 50 degrees Fahrenheit, respectively, which were not in compliance with food safety standards. The Food Service Director confirmed that both hot and cold food temperatures should be measured by dietary staff prior to meal services to prevent food from entering the danger zone, where bacteria can grow rapidly.
Inoperable Dishwashing Machine Since January 2024
Penalty
Summary
The facility failed to maintain its mechanical dishwashing machine in safe operating condition, as identified during a kitchen tour on October 16, 2024. The dishwashing machine had been out of order since January 2024. According to the facility's policy, any issues with the dishwashing machine should be reported to the Food Production Manager, who would then coordinate with Plant Operations for repairs. However, despite receiving a repair quote in December 2023 and approval from the administration, the necessary parts for repair were delayed, and the machine remained inoperable. Interviews revealed that the current Food Service Director, who started approximately four months prior to the survey, had been working with various vendors to obtain proposals for new dishwashing equipment. A quote for new equipment was dated September 27, 2024. The Administrator confirmed that the dishwashing machine had been inoperable since January 2024 and that the facility's ownership was hesitant to commit funds for repair or replacement due to potential closure or sale plans earlier in the year. This inaction resulted in the continued non-functionality of the dishwashing machine, impacting the facility's ability to maintain equipment in safe operating condition.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined the clinical appropriateness of self-administration of medications for a resident. Specifically, a resident with diagnoses including paraplegia, COPD, and edema was self-administering a nasal moisturizing spray without a documented assessment or a physician's order for self-administration. The resident had a BIMS score indicating intact cognition and was receiving respiratory treatment, including oxygen therapy. Despite this, there was no evidence in the medical records of an assessment to determine the resident's capability to self-administer the nasal spray safely. Observations and interviews revealed that the resident was allowed to self-administer the nasal spray, with nurses leaving the spray bottle with the resident and later signing the EMAR as if they had administered it. Both a registered nurse and an LPN confirmed that the resident self-administered the nasal spray, and the spray was stored in the medication cart at the end of each shift. The Director of Nursing Services acknowledged that the resident should have been assessed for competency in self-administration and that a physician's order should have been obtained.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as evidenced by the condition of the privacy curtain in a resident's room on Unit Seacliff 1. The curtain was observed to be ripped and stained with brown marks during an environmental tour. The facility's policy on Resident Room Cleaning, dated March 2022, did not specify when curtains should be changed or washed, which contributed to the oversight. The resident, who had intact cognition and diagnoses including Polyneuropathy, Type 2 Diabetes Mellitus, and Major Depressive Disorder, confirmed that the curtain had been in this condition since their admission and expressed a desire for a clean and intact curtain. Interviews with facility staff revealed a breakdown in communication regarding the maintenance of the resident's environment. Certified Nursing Assistants were aware of the issue and had informed a nurse, but the nurse was not identified, and the information was not relayed to housekeeping. The Housekeeper Supervisor stated that curtains are typically replaced every three to four weeks but was unaware of the specific issue with the resident's curtain. This lack of communication and clarity in procedures led to the deficiency in maintaining a homelike environment for the resident.
Inaccurate MDS Assessment for Comfort Care
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the provision of comfort care. This deficiency was identified during a recertification survey for one resident out of a sample of 38. The resident in question had a history of Alzheimer's disease, Bipolar Disorder, and Diabetes Mellitus, and was documented to have severely impaired cognition. Despite having a physician's order for Comfort Measures Only (CMO) since February 2023, the MDS assessment inaccurately indicated that comfort care was not provided in the last 14 days. Interviews with facility staff revealed that the MDS Director acknowledged the error, stating that the resident had been on comfort care as per the physician's orders. The Director of Nursing Services confirmed that the MDS Coordinators and the MDS Director were responsible for ensuring the accuracy of the MDS assessments and that the provision of comfort care should have been correctly documented. The facility's policy on the completion of the Resident Assessment Instrument (RAI) process was not adhered to, leading to this oversight.
Failure to Develop Comprehensive Care Plan for Infection Control
Penalty
Summary
The facility failed to develop a person-centered Comprehensive Care Plan (CCP) for a resident who was placed on contact precautions due to a drug-resistant Pseudomonas infection. The resident, who had a history of cerebral infarction, was ventilator-dependent, and had a tracheostomy, was readmitted to the facility in May 2024 with a physician's order for contact precautions. However, there was no documented evidence of a care plan addressing these precautions until October 16, 2024. Interviews with facility staff revealed a lack of clarity regarding responsibility for developing and updating care plans. The Infection Control Nurse acknowledged the oversight, stating they were responsible for managing infection-related care plans but failed to do so for this resident. The Minimum Data Set Director and the Director of Nursing Services also confirmed that an isolation care plan should have been developed, indicating a breakdown in communication and responsibility among the staff.
Medication Administration Error Due to Improper Labeling and Resident Identification
Penalty
Summary
During a recertification survey, it was observed that a Licensed Practical Nurse (LPN) on the Woodcrest 2 unit of the facility did not adhere to professional standards of medication administration. The LPN pre-poured medications into a cup and stored it in the medication cart without proper labeling. This action was contrary to the facility's medication administration policy, which requires medications to be prepared in a clean area and administered according to each resident's care plan and physician's orders. The policy also mandates verifying the resident's identity using two identifiers before administering medication. The incident involved Resident #100, who had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor, with intact cognition as per their assessment. The LPN attempted to administer the pre-poured medications to Resident #100, who was not the intended recipient and had already received their morning medications. The LPN, who was a float nurse, admitted to not verifying the resident's identity and mistakenly believed Resident #100 resided in a different room. The Director of Nursing Services confirmed that the LPN failed to follow the facility's policy of the five rights of medication administration, which includes ensuring the right resident, medication, time, dose, and route.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency identified during a recertification survey. The resident, who weighed 86 pounds and had multiple unstageable pressure ulcers, was prescribed an alternating air mattress to aid in pressure relief and wound healing. However, the air mattress was set to a firm setting suitable for a person weighing between 360-400 pounds, rendering it deflated and non-functional, which was not consistent with the resident's weight and needs. The facility's policy on pressure ulcer management emphasizes an interdisciplinary approach to reduce causative factors and promote healing. Despite this, the air mattress settings were not adjusted according to the resident's weight, and the malfunctioning mattress was not addressed promptly. Various staff members, including LPNs and CNAs, were responsible for monitoring the mattress but failed to check or adjust the weight settings. The housekeeping staff, who were reportedly responsible for adjusting the settings, did not do so, and the malfunction was only identified during the survey. Interviews with staff revealed a lack of clarity and responsibility regarding the adjustment and monitoring of the air mattress settings. The Director of Nursing Services stated that unit nurses should check the mattress settings each shift and report any issues, but this protocol was not followed. The oversight in monitoring and adjusting the air mattress settings contributed to the deficiency in providing necessary treatment and services to prevent further pressure ulcers and promote healing for the resident.
Unsecured Oxygen Tank Poses Hazard
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, as observed during a recertification survey. Specifically, an unsecured, free-standing oxygen E-Cylinder tank was found next to a resident's bed. The facility's policy requires that such tanks be secured in a rolling cylinder stand to prevent accidents. The resident, who had severe cognitive impairment and a history of Alzheimer's, diabetes, and acute cough, did not have a current physician's order for oxygen use. Despite this, the oxygen tank remained in the room, unsecured, with a nebulizer mask and tubing attached. Interviews with staff revealed a lack of awareness and adherence to the facility's safety protocols. A Licensed Practical Nurse and a Certified Nursing Assistant both failed to notice the unsecured tank, while a Registered Nurse admitted to using the tank for nebulization due to the unavailability of a nebulizer machine, despite the order for nebulization being discontinued. The Director of Plant Operation and the Director of Nursing Services both confirmed that the oxygen tanks should have been secured and that the facility had sufficient nebulizer machines, indicating a lapse in communication and protocol enforcement.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain accurate records and accounts of controlled drugs, as observed during a recertification survey. Specifically, discrepancies were found in the Controlled Substance Disposition Records for two residents. One resident's record for Oxycontin was not updated after administration, resulting in a mismatch between the recorded and actual number of tablets. Similarly, another resident's record for Tramadol was not reconciled, leading to a discrepancy in the tablet count. Additionally, a blister pack of Marinol was found without a corresponding Controlled Substance Disposition Record, indicating a lack of proper documentation and reconciliation for this medication. During the survey, it was also observed that pre-poured medications were stored in a medication cart without proper identification, leading to an attempt to administer the wrong medications to a resident. An LPN, who was a float nurse, mistakenly offered medications intended for another resident, failing to verify the resident's identity using two patient identifiers. This incident highlighted a breach in the facility's medication administration policy, which requires immediate administration of medications after preparation and verification of the resident's identity. Interviews with nursing staff revealed a lack of adherence to established procedures for handling and documenting controlled substances. An LPN admitted to not signing the Controlled Substance Disposition Record due to rushing, and there was a lack of awareness regarding the procedure for storing discontinued controlled medications. The Director of Nursing Services confirmed that the proper process for reconciling controlled drugs was not followed, and the facility's policy on medication administration was not adhered to, resulting in these deficiencies.
Improper Medication Storage Temperature in Nursing Unit
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored under proper temperature control, as observed during a recertification survey. Specifically, the medication refrigerator in the [NAME] 2 Nursing Unit was found to be at 60 degrees Fahrenheit, which is above the manufacturer's recommended storage temperature of 36 to 46 degrees Fahrenheit for the insulin injection pens and Trulicity injection pens stored inside. This discrepancy was noted during a Medication Storage and Labeling Task, highlighting a failure to adhere to the facility's policy and procedure for the storage of medications requiring refrigeration. During the survey, it was revealed that the temperature of the medication refrigerator was not consistently monitored or documented, as evidenced by the absence of a daily temperature log sheet. Registered Nurse #6 was unaware of whether the temperature had been checked on the morning of the observation and did not know the acceptable temperature range for the medications. The Director of Nursing Services confirmed that the temperature should be checked every shift and that any issues with the refrigerator should be reported to the Maintenance Department, indicating a lapse in the facility's protocol adherence and staff awareness.
Failure to Conduct Timely Laboratory Tests
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident, identified as Resident #108, who was reviewed for unnecessary medications. A Lipid Profile was ordered in response to a pharmacist's medication regimen review, but the test was not communicated to the laboratory and therefore was not conducted. The resident, who had diagnoses including Non-Alzheimer's Dementia, Diabetes Mellitus, and Depression, was on Quetiapine, an antipsychotic medication. The medication regimen review recommended a Lipid Profile three months after starting the medication and annually thereafter, which the physician agreed to. However, despite being ordered in the electronic medical record on two occasions, the Lipid Profile was not performed. Interviews with facility staff revealed a two-step system for ordering lab work, which involves entering the order into the electronic medical record and notifying the laboratory through a separate system. The facility's electronic medical record is not interfaced with the laboratory, which contributed to the oversight. The Director of Nursing Services and other staff members acknowledged the issue but could not provide an explanation for the failure to conduct the Lipid Profile. The deficiency was identified during a recertification survey, highlighting a lapse in the facility's process for ensuring timely laboratory services.
Deficiency in Documentation of Oxygen Therapy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving respiratory care, specifically oxygen therapy. During a recertification survey, it was observed that the resident was receiving oxygen therapy via a nasal cannula on multiple occasions as per the physician's order. However, there was no documented evidence in the Treatment Administration Record that the oxygen therapy was administered on the observed dates. This lack of documentation was contrary to the facility's policy, which requires licensed nurses to document medication and treatment administration immediately after it is given. The resident in question had a history of sepsis and pneumonia and was cognitively impaired, as indicated by a low score on the Brief Interview for Mental Status. Despite having a physician's order for oxygen therapy, the Treatment Administration Record did not reflect the administration of oxygen from the beginning of October until the order was discontinued. Interviews with nursing staff, including an LPN and the charge nurse, revealed that the responsibility for documenting oxygen administration was understood but not executed. The Director of Nursing Services confirmed that the documentation should have been completed as per the facility's policy.
Unauthorized Withdrawal of Resident's Funds by LPN
Penalty
Summary
The facility did not ensure that Resident #1 was free from misappropriation of property and exploitation. Resident #1, who had intact cognition, reported that their bank card was used by an LPN to withdraw $1,000 without authorization. The resident initially gave the LPN the card to withdraw $800 to repay a debt for food purchases, but later discovered an additional $200 was withdrawn without their consent. Despite the resident's refusal to press charges or provide bank statements, the facility's investigation confirmed the unauthorized withdrawal, leading to the termination of the LPN involved. The facility's policies on abuse prevention and non-fraternization were not adhered to, as the LPN engaged in a financial transaction with the resident, which is against the facility's rules. The resident's care plan indicated a risk for abuse and victimization, yet the facility failed to maintain a safe environment as required. The resident's report to the Director of Nursing Services and the Social Worker highlighted the unauthorized withdrawal, but the resident's reluctance to provide further evidence complicated the investigation. Interviews with the involved parties revealed discrepancies in the accounts of the withdrawal. The LPN claimed to have withdrawn the money at the resident's request and returned most of it, while the resident expressed concerns for the LPN's well-being and did not want to pursue further action. The facility's response included contacting the police, but the resident's refusal to file a formal report limited the investigation's scope. Ultimately, the facility terminated the LPN based on the resident's initial report and the violation of facility policies.
Delay in Emergency Response Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received timely emergency medical treatment, resulting in actual harm and immediate jeopardy. On the evening of the incident, a resident experienced respiratory distress and was assessed by a Nurse Practitioner who ordered an immediate transfer to the hospital. However, the Registered Nurse on duty called a non-emergency ambulance service instead of emergency medical services, leading to a significant delay in the resident's transfer. The resident, who was ventilator-dependent and had a history of severe medical conditions including anoxic encephalopathy and chronic embolisms, was in a critical state with symptoms such as tachycardia and low oxygen saturation. Despite the Nurse Practitioner's order for immediate hospital transfer, the Registered Nurse did not follow the directive to call emergency services, resulting in a delay of 1 hour and 33 minutes before emergency services were finally contacted at the insistence of the resident's family. The delay in calling emergency services contributed to the resident's death from cardiorespiratory arrest due to respiratory failure. The facility's existing policy did not provide clear guidance on when to contact emergency medical services, and staff interviews revealed a lack of understanding and communication regarding the urgency of the situation. This deficiency highlights a critical lapse in the facility's emergency response protocol, impacting the quality of care provided to the resident.
Inadequate Supervision Leads to Smoking-Related Injury in Resident Using Oxygen Therapy
Penalty
Summary
During an abbreviated survey at a nursing home, it was found that the facility failed to ensure adequate supervision to prevent accidents for Resident #1, who had a history of unsafe smoking and utilized supplemental oxygen therapy for Chronic Obstructive Pulmonary Disease. Despite being aware of the resident's noncompliance with smoking policies, the facility did not implement interventions to maintain the resident's safety. Resident #1 sustained a burn to their face while smoking unsupervised with oxygen, resulting in actual harm and Immediate Jeopardy. The facility's smoking policy lacked specific guidelines on supervision and monitoring of residents to prevent smoking-related accidents. Resident #1's history of noncompliance with smoking policies, coupled with the lack of increased supervision or monitoring after previous incidents, contributed to the deficiency. The resident's ability to independently move around the facility, coupled with their intact cognition, further complicated the situation. Interviews with staff members revealed gaps in monitoring and addressing Resident #1's smoking behavior, especially in the context of using oxygen therapy. The facility's failure to reassess or educate the resident on safe smoking practices while using oxygen, as well as the inability to determine the source of cigarettes and lighters in the resident's possession, were highlighted as contributing factors to the deficiency.
Failure to Monitor Smoking Noncompliance
Penalty
Summary
The Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) committee failed to monitor interventions and implement an appropriate plan of action for a quality deficiency regarding smoking noncompliance. This failure resulted in non-compliance with regulations related to smoking safety and was identified during an abbreviated survey. The facility's policy dated 05/03/2023 stated that it would maintain an effective, comprehensive, data-driven QAPI program focusing on care outcomes and quality of life. However, an Immediate Jeopardy was called on 02/29/2024 due to smoking noncompliance involving one resident, leading to an extended survey completed on 03/04/2024. The QAPI committee notes from 06/01/2023 and 08/30/2023 documented interventions such as random administrative supervision at smoking sessions and courtyard supervision every half hour. Despite these measures, the facility did not provide documented evidence that the QAPI committee followed through with the performance improvement plan to ensure compliance with the smoking policy. Interviews with the Administrator, Director of Nursing, and Registered Nurse Consultant confirmed that smoking noncompliance was identified in June 2023, discussed again in August 2023, but had not been addressed in subsequent QAPI meetings. The Administrator acknowledged that smoking remains an ongoing issue and emphasized the need for more frequent monitoring and follow-up by the QAPI committee.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the New York State Department of Health. This deficiency was identified when a resident complained that a Certified Nursing Aide (CNA) handled them roughly during care. The resident reported that the CNA grabbed their left arm, twisted it, and pushed them to turn. Despite the resident's complaint being reported to the nursing supervisor, the incident was not reported to the New York State Department of Health within the required 24-hour timeframe. The facility's policies required immediate reporting of any suspected abuse, neglect, or mistreatment to the Director of Nursing and/or Administrator, who would then report it to the New York State Department of Health. However, the incident involving the resident and the CNA was not reported until several days later. The resident initially reported the incident to a Registered Nurse, who then informed the nursing supervisor. The nursing supervisor admitted that they forgot to report the incident immediately due to other ongoing activities. Interviews with various staff members, including the Registered Nurse, the nursing supervisor, the social worker, the Assistant Director of Nursing, and the Director of Nursing Service, confirmed that the incident was not reported in a timely manner. The social worker and the Assistant Director of Nursing both acknowledged that the incident should have been reported immediately to initiate an investigation and notify the New York State Department of Health. The delay in reporting and investigating the incident led to the identification of this deficiency during the complaint investigation.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 742 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
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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, | 0.7 mi | ★★★★★ | 0 | 0 |
| White Oaks Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Central Island Healthcare | 3.6 mi | ★★★★★ | 0 | 0 |
| Huntington Hills Center For Health And Rehabilitat | 3.9 mi | ★★★★★ | 0 | 0 |
| Apex Rehabilitation & Care Center | 4 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 July 2026) and official state health department websites.