Excel at Woodbury for Rehabilitation and Nursing,

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs for one (Resident #82) of two residents reviewed for Skin Conditions and one (Resident #64) of one resident reviewed for Edema. Specifically, 1) Resident #82 was admitted to the facility with a condition identified by the Physician as possible Melanoma (the most serious form of skin cancer). The location of the skin lesion was not identified in the medical record, and a comprehensive care plan was not created with nursing interventions for monitoring and care; [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #7) of three residents reviewed for Accidents. Specifically, Resident #7 was observed with a tube of Lidocaine (a topical anesthetic that provides temporary pain relief by numbing the applied area) 5 percent ointment on Resident #7's overbed table. Additionally, there was an open storage box on top of Resident #7's overbed table containing two bottles of unlabeled glucose 4-gram tablets (treat low blood sugar). There was no Nursing staff in the vicinity of Resident #7's room. Resident #7 was not assessed to administer their medications. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure all comprehensive resident assessments were completed according to the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, including the Minimum Date Set assessment completion date must be no later than 14 days after the Assesssment Reference date. This was identified for one (Resident #44) of six residents reviewed for the Resident Assessment Task. Specifically, Resident #44's Annual Minimum Data Set assessment, with Assessment Reference Date of 10/3/2024, was not completed until 11/13/2024, 27 days after the completion due date. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion. This was identified for one (Resident #44) of six residents reviewed for the Resident Assessment Task. Specifically, Resident #44's Quarterly Minimum Data Set assessment dated [DATE] and Annual Minimum Data Set assessment dated [DATE] were transmitted more than 14 days after the assessment completion date. Additionally, there was no documented evidence that Resident #44's Significant Change in Status assessment dated [DATE] was transmitted to the Center for Medicare and Medicaid Services. [...]

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00319453) completed on 4/23/2024, the facility did not ensure resident rights to be free from abuse. This was identified for one (Resident #311) of two Residents reviewed for Abuse. Specifically, Resident #311 who had a history of verbally disruptive and intrusive behavior such as attempts to enter other resident rooms, antagonize residents, excessive talking, inappropriate outbursts, and mocking other residents, was transferred to Resident #310's unit on 5/3/2023 after returning from emergency room status post verbal altercation with a resident on the previous unit. Resident #311 continued to have disruptive behaviors including paranoia, agitation, incessant speaking, and being accusatory toward others on the newly assigned unit. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/16/2024 and completed on 4/23/2024, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that includes measurable objectives and timeframes to meet resident's medical and nursing needs. This was identified for one (Resident #16) of one resident reviewed for position and mobility. Specifically, Resident #16 had a physician's order for a hip abduction flexion contracture cushion (abduction pillow) to be worn at all times. During observations on 4/17/2024 at 9:00 AM and on 4/19/2024 at 9:00 AM Resident #16 was observed in bed without a hip abduction flexion contracture cushion. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/16/2024 and completed on 4/23/2024, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #312) of four residents reviewed for medication administration. Specifically, during the medication pass observation on 4/17/2024 for Resident #312, the labels on the medication blister packs, for physician-prescribed Allopurinol (a medication to reduce uric acid to treat gout and kidney stones) and Torsemide (a diuretic to help reduce fluid in the body), did not match the physician orders. The finding is: [...]

Inspectors wroteBased on observation and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00279190, NY 00283964) initiated on 9/18/2022 and completed on 9/22/2022, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 3 residents units, the kitchen and the basement. Specifically, floors were soiled with litter and sticky substances, and exhausts vents contained a build-up of dust. The finding is: During a tour of the facility on 9/21/2022 to 9/22/2022, the following was observed: (1) the Kitchen Storage room located in the basement contained a sticky substance on the floor. Within the substance were 3 bugs lying on their backs. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY00279190, NY00283964) initiated on 9/18/2022 and completed on 9/22/2022, the facility failed to maintain an effective pest control program so that the facility was free of pests. Specifically, there was evidence of bugs in the kitchen, kitchen storage room, and on the B wing. The finding is: On 9/21/2022 at 8:40 AM, a brown bug with antenna measuring 1 inch in length, was observed on the B unit between room [ROOM NUMBER] and 136. On 9/21/2022 at 10:20 AM, 3 bugs lying on their backs, were observed on the floor in the kitchen storage room. On 9/21/2022 at 10:45 AM, 2 brown bugs measuring 1/8 inch in length were observed walking on the floor below the dishwasher in the kitchen. Resident #59 was observed in the hallway on 9/18/22 at 1:20 PM. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00295436) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not inform the resident's Designated Representative (DR) when a new form of treatment was started. This was identified for one (Resident #90) of six residents reviewed for Unnecessary Medications. Specifically, there was no documented evidence that Resident #190's DR was notified 1) when the resident's Zoloft (an antidepressant medication) dosage was increased on 1/7/2022 and 2) when the resident was started on Remeron (an antidepressant medication often used to increase appetite) on 1/4/2022. The finding is: [...]

Inspectors wroteBased on interviews and record review during the Recertification survey and Abbreviated survey (NY00282386) initiated on 9/18/2022 and completed on 9/22/2022 the facility did not ensure that all allegations of abuse were thoroughly investigated. This was identified for one (Resident #187) of one Resident reviewed for Abuse. Specifically, Resident #187 complained that three facility staff handled the resident roughly during a transfer from one surface to another. The facility investigation did not include all statements necessary to rule out abuse, neglect, and mistreatment including a statement from Resident #187's assigned Certified Nursing Assistant (CNA) #4. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00295436) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed to meet each resident's individualized care needs. This was identified for one (Resident #190) of one resident reviewed for Unnecessary Medications. Specifically, Resident #190 had a diagnosis of Diabetes Mellitus (DM) and had a Physician's Order to receive finger sticks without coverage four times a day. There was no CCP developed to address the DM diagnosis and blood sugar monitoring. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification survey and Abbreviated survey (NY00287018) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #189) of one resident reviewed for change of condition. Specifically, Resident #189 had a Pleurx catheter (a drainage system that allows for the drainage of pleural effusion, which is a build-up of fluid in the chest) with orders for the catheter to be drained two times per week. On 11/8/2021 the drainage of the catheter was scheduled; however, the treatment was not administered, although there was qualified staff in the facility that day to provide the treatment. [...]