378 Syosset Woodbury Road, Woodbury, NY 11797 · Nassau County · (516) 921-3900
606 certified beds, about 278 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1977
CMS Care Compare ratings, data as of September 1, 2026 · CCN 335555 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on October 23, 2024, inspectors cited 14 health deficiencies (the New York average is 8.1, the national average 9.2).
Of 46 health citations since May 2021, 4 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 1 fine totaling $117,712 in the last three years; the largest was $117,712, and the latest is dated February 12, 2024.
Nurses and nurse aides worked 3.49 hours per resident per day, against 3.63 across New York and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.
44.7% of nursing staff left within the year CMS measured (New York average 40.3%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident was treated with respect and dignity and in a manner that promotes maintenance or enhancement of his or her quality of life. This was identified 1) on nine of nine units during the dining task observations and 2) for seven (Resident #169, Resident #341, Resident #285, Resident #5, Resident #267, Resident #337, and Resident #204) of seven residents interviewed during the resident council meeting. Specifically, 1)during the dining task observations, residents on all nine units were served their breakfast and lunch meals on disposable plates with disposable utensils. [...]
Inspectors wroteBased on observation, interviews, and record review, during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility failed to ensure that food was served in accordance with professional standards for food service safety. This was identified for one unit (Woodcrest one) of nine units observed during the Dining Facility Task. Specifically, the facility did not monitor the temperature of cold food items served to residents in the Woodcrest One Unit during a lunch meal observation on 10/16/2024. The cold food temperature served during the lunch meal measured between 50-60 degrees Fahrenheit (normal range: below 41 degrees Fahrenheit). The finding is: An undated facility policy and procedure titled Food Temperatures documented that the temperatures of the food items will be taken and properly recorded for each meal. [...]
Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was identified during the Kitchen Task. Specifically, during a kitchen tour with the Food Production Manager on 10/16/2024 the mechanical dishwashing machine was not in working order. Record review and interviews indicated that the dishwashing machine has been out of order since January 2024. The finding is: A facility policy and procedure dated 4/20/2023 titled Dishwashing, documented the Nutritional Services Department shall maintain a file of written procedures for cleaning and maintaining all equipment in the department. [...]
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024 the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (Resident #79) of six residents reviewed for Accidents. Specifically, Resident #79 was self-administering the Nasal Moisturizing Spray and the facility staff was aware. A review of the resident's medical records indicated no documented assessment to determine if the resident could safely self-administer the medication and there was no physician's order to self-administer the Nasal Moisturizing Spray. The finding is: [...]
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident was provided a safe, clean, comfortable, and homelike environment. This was identified for one (Unit Seacliff 1) of nine units observed during the environmental task. Specifically, Resident #246 's privacy curtain was ripped and had brown stains. The finding is: The facility's policy for Resident Room Cleaning, dated March 2022, documented meaning and sanitizing to improve sanitation and ensure the highest level of cleanliness throughout the facility. To control cross-contamination, and the spread of bacteria and infection to maintain the outward experience of the facility. [...]
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflects the resident's status. This was identified for one (Resident #262) of 38 sampled residents. Specifically, the Minimum Data Set assessment for Resident #262 did not accurately indicate that the resident was receiving comfort care. The finding is: The facility policy and procedure titled Completion of the RAI Process last reviewed 3/16/2023, documented that assessments will be completed within the guidelines outlined in the Resident Assessment Instrument (RAI) manual, including the care planning processes to lead to the development of a plan of care to address and monitor each resident's needs and function, and to track changes in the resident's status. [...]
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/24/2024, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed to meet the resident's medical and nursing needs. This was identified for one (Resident #331) of four residents reviewed during the Infection Control Task. Specifically, Resident #331 had a physician's order to place Resident #331 on contact precautions since 5/22/2024. There was no documented evidence that a care plan was developed to reflect Resident #331 was on contact precaution until 10/16/2024. The finding is: The Comprehensive Care Plan Policy dated 2/01/2021 documented that residents of the facility will have a Comprehensive Care Plan completed per Federal and State requirements. [...]
Inspectors wroteBased on observation, record review, and staff interviews during a recertification survey initiated on 10/16/2024 and completed on 10/24/2024, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. The was identified on one (Woodcrest 2 unit) of nine units observed for medication storage task. Specifically, Licensed Practical Nurse #9 pre-poured medications in a medication cup and stored the medication cup in the medication cart without appropriate labels. Licensed Practical Nurse #9 then attempted to administer the medications to the wrong resident (Resident #100) without properly identifying the resident. The finding is: The Medication administration policy dated 9/07/2023 documented Medication administration will be conducted according to each resident's individualized care plan and physician's orders. [...]
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #176) of three residents reviewed for Pressure Ulcers. Specifically, Resident #176 had a physician's order for an alternating air mattress due to multiple pressure ulcers. The resident's most recent weight was 86 pounds. The air mattress weight setting was set to a firm setting which corresponds to a resident who weighs between 360-400 pounds; however, the air mattress was observed to be deflated and was not functioning as intended. The finding is: [...]
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #243) of six residents reviewed for Accident Hazards. Specifically, Resident #243's room was observed with an unsecured, free-standing oxygen E-Cylinder tank (the most common and largest portable oxygen tank) next to the resident's bed. The E-Cylinder tank was not secured in a rolling cylinder stand as per the facility's policy. The finding is: The facility policy and procedure titled Oxygen safety, last revised on 5/4/2024 documented that safety is the responsibility of all staff, residents, visitors, and the public. [...]
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a system of records and accounts of all controlled drugs were maintained, and the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for three (Resident #207, Resident #301, and Resident #340) of three residents reviewed during the medication storage task and 2) one (Woodcrest 2 Unit) of nine units observed during the medication storage task. Specifically, 1) Resident #207 and Resident #301 Controlled Substance Disposition Record were not accurately reconciled after the medications were administered to the residents. [...]
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure all drugs and biologicals used in the facility were maintained and stored under proper temperature control. This was identified during a Medication Storage and Labeling Task on one ([NAME] 2 Unit) of nine Nursing Units observed. Specifically, [NAME] 2 Nursing Unit medication refrigerator temperature was observed to be at 60 degrees Fahrenheit. There were two unused/unopened Insulin injection pens and a box of Trulicity (used for Diabetes) injection pens observed stored in the medication refrigerator. Both unopened medications were supposed to be stored in the refrigerator at a temperature between 36 degrees Fahrenheit to 46 degrees Fahrenheit as per the manufacturer's recommendations. The finding is: [...]
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure laboratory services were obtained in a timely fashion to meet the needs of each resident. This was identified for one (Resident #108) of five residents reviewed for Unnecessary Medications. Specifically, a Lipid Profile (a blood test to determine different types of fat in the blood) was ordered for Resident #108 in response to a pharmacist medication regimen review. The blood test was ordered in the electronic medical record on 9/27/2024 and 10/11/2024 but was not communicated to the laboratory and therefore was not done. The finding is: [...]
Inspectors wroteBased on observations, interviews, and record review during a Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that medical records were maintained for each resident that were complete and accurately documented in accordance with accepted professional standards of practice. This was identified for one (Resident #184) of one resident reviewed for Respiratory Care. Specifically, Resident #184 was observed receiving oxygen therapy via a nasal cannula on 10/16/2024, 10/17/2024, and 10/21/2024 as per their Physician's order; however, there was no documented evidence that the resident was administered oxygen therapy on 10/16/2024, 10/17/2024, and 10/21/2024. The finding is: [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during a complaint investigation survey NY00337265, the facility did not ensure each resident was free from misappropriation of the resident's property and exploitation. This was identified for one (Resident #1) of three residents reviewed. Specifically, Resident #1's bank card was used by Licensed Practical Nurse #1 to withdraw money totaling 1,000 dollars without the resident's authorization.
Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (NY00322869) initiated on [DATE] the facility failed to ensure that each resident receive treatment and care in accordance with professional standards of practice for 1 out of 5 residents (Resident #1). Specifically, on [DATE] at 6:05 PM Resident #1 experienced respiratory distress. At 7:55 PM Nurse Practitioner #1 assessed the resident and ordered the resident to be transferred to the hospital. Registered Nurse #1 did not follow the order to call for emergency medical transportation, instead Registered Nurse #1 called a non-emergency ambulance service. The company reported that it would take 2 hours for the ambulance to arrive. The resident's family intervened at approximately 9:00 PM and demanded that emergency services (911) be called. [...]
Inspectors wroteBased on observation, record review and interview during an abbreviated survey (NY00334107), the facility failed to have a system in place to ensure that each resident received adequate supervision to prevent accidents. Specifically, Resident #1 had a history of unsafe smoking and was found by facility staff smoking unsupervised outside of the designated time on four occasions. The facility staff were aware of the resident's noncompliance with smoking; however, there were no interventions put in place to maintain the resident's safety. Resident #1 utilized supplemental oxygen therapy for the diagnosis of Chronic Obstructive Pulmonary Disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). [...]
Inspectors wroteBased on staff interview and facility document review, the QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement) committee failed to monitor interventions and implement an appropriate plan of action for an identified quality deficiency regarding smoking noncompliance. This failure resulted in non-compliance in regulations related to smoking safety and noncompliance during an abbreviated survey.
Inspectors wroteBased on observations, record reviews and interviews conducted during a complaint investigation, Complaint # NY00332067 initiated on 2/8/2024 and completed on 2/12/2024, 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 was identified for one (Resident #1) of three residents reviewed for Abuse. Specifically, the facility did not report an allegation of physical abuse to the New York State Department of Health within 24 hours when Resident #1 complained that Certified Nursing Aide #1 handled the resident roughly during care and it was reported to the nursing supervisor. The resident stated Certified Nursing Assistant #1 grabbed the resident's left arm, twisted, and pushed to turn the resident.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00310476) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #738) of four residents reviewed for Pressure Ulcers. Specifically, Resident #738 was admitted to the facility with an unstageable pressure ulcer to the sacral region which deteriorated to a Stage 4 pressure ulcer. The resident was identified as a high risk for pressure ulcer development. [...]
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that pain management was provided to each resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #116) of two residents reviewed for Pain Management. Specifically, Resident #116 with diagnosis of Multiple Sclerosis (MS-a chronic disease of the central nervous system) had a Physician's order to receive Baclofen (a muscle relaxant) 10 milligrams (mg), give two tablets 20 mg every 12 hours at 6:00 AM and 6:00 PM for muscle spasms. Resident #116 did not receive the 6:00 PM dose of Baclofen on 7/22/2023. [...]
Inspectors wroteBased on observations, record review and interviews during the Recertification and Abbreviated surveys (NY00304799 and NY00320391) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure nursing services are provided by sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. [...]
Inspectors wroteBased on observations, record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was not effectively administered to ensure sufficient staffing was provided to promote the highest practicable physical mental and psychosocial well-being of each resident. The Facility Assessment did not include the overall number of facility staff needed to ensure that each resident's needs were being met. Additionally, the Administrator did not monitor and enhance the quality of care and services by repeating the same deficiencies including: [...]
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure sufficient number of qualified staff required to meet each resident's needs. The facility assessment did not consider a review of individual staff assignment and systems for coordination and continuity of care for resident's within and across these staff assignments. Additionally, the facility assessment did not include the need for the respiratory care clinicians on the ventilator unit. The finding is: [...]
Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident is treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (Resident #224) of one resident reviewed for resident rights. Specifically, during a lunch meal observation on 8/1/2023 at time 1:05 PM Registered Nurse (RN) #13 was observed standing over Resident #224 while feeding the resident. The finding is: The facility's policy titled Assisting with Feeding dated 10/26/2022 documented to provide assistance with feeding to residents who require it as part of their care plan in the nursing home. [...]
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00309550) initiated on [DATE] and completed on [DATE], the facility did not ensure that residents and/or their Designated Representatives participated in the development and implementation of his or her person-centered plan of care. This was identified for one (Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that Resident #43 had a Comprehensive Care Plan (CCP) meeting held since [DATE]. Additionally, there was no documented evidence that the resident's Health Care Proxy (HCP)/Designated Representative was invited to a CCP meeting since [DATE]. The finding is: [...]
Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00310476 and NY00309550) initiated on [DATE] and completed on [DATE], the facility did not immediately consult with the resident's Physician and/or notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for two (Resident #738 and Resident #43) of four residents reviewed for Notification of Change. [...]
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on two of three nursing units in the Woodcrest Building. Specifically, on 8/4/2023 on the Woodcrest 1 unit there was an upholstered couch used by residents in the common area that was soiled and stained; and on Woodcrest 3 unit there were two upholstered chairs used by residents in the common area that were soiled and stained. The finding is: The facility's policy titled, Cleaning Furnishings, dated 6/1/2022, documented to create a clean and hygienic environment for residents, staff, and visitors, promoting infection prevention and overall well-being. [...]
Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that all residents were free from physical restraints imposed for the purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was identified for one (Resident #455) of one resident reviewed for restraints. Specifically, Resident #455 was observed in their bed with the right side of the bed placed against the wall. On the left side of the bed three pillows were observed folded in half and wedged between the mattress and bed frame which caused the mattress to curve upward and prevented the resident for exiting the bed. There was not a physician's order or an assessment for the use of pillows to prevent the resident from exiting the bed. The finding is: [...]
Inspectors wroteBased on observations, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was identified for one (Resident #91) of one resident reviewed for Dialysis. Specifically, there was no Dialysis or Renal care plan created for Resident #91, who received bedside dialysis in the facility. The finding is: The facility's policy titled Comprehensive Care Plan, dated 2/1/2021, documented residents of the facility will have a Comprehensive Care Plan (CCP) completed in accordance with Federal and State requirements. The CCP will include the resident's problems, strengths, and needs. [...]
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that services were provided or arranged by the facility, as outlined by the comprehensive care plan, to meet professional standards of quality. This was identified for two (Resident #91 and #422) of 27 residents observed during the initial tour on Seacliff 1 unit. Specifically, Resident #91's and #422's tube feeding bottles were not labeled with the resident name, date, or start time.
Inspectors wroteBased on observation, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain grooming, and personal hygiene for one (Resident#343) of eight residents reviewed for ADLs. Specifically, on 8/1/2023 Resident #343 was observed lying in bed in a hospital gown with a towel over their chest and abdomen. Coffee had spilled onto the towel, the resident's call bell was behind the resident on the head board and the resident's fingernails were observed to be long, untrimmed, and dirty on both hands. The finding is: The facility's policy titled Activities of Daily Living - General, dated 5/1/2021, documented to ensure residents receive all necessary care including activities of daily living. [...]
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for 1) one (Resident #318) of three residents reviewed for skin conditions and 2) for one (Resident #455) of one resident reviewed for Restraints. Specifically, 1) Resident #318 did not receive the physician ordered wound treatment to the resident's bilateral legs on 8/6/2023. 2) Resident #455 with diagnoses including crushing injury of the head and traumatic hemorrhage of the cerebrum (brain), had a physician's order to utilize a helmet at all times and on six occasions Resident #455 was observed without wearing the helmet. [...]
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure the resident environment remained as free of accident hazards as is possible. This was identified for one (Resident #39) of four residents observed for medication administration. Specifically, during the medication pass observation conducted on 8/2/2023 Resident #39 was observed with a bottle of Tylenol PM (pain medication also used to assist with sleeping), antacid tablets, and a tube of Icy-Hot pain cream at the resident's bedside. There was no Physician's order for the Tylenol PM, antacid tablets, or tube of Icy-Hot pain cream and the resident was not assessed to self-medicate. The finding is: [...]
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that medications were administered within one hour of the ordered administration time. This was identified for 1) one of three units in the [NAME] building on 8/1/2023; 2) one of three units in the Sagamore building on 8/6/2023; and 3) the facility did not ensure that an account of controlled drugs was maintained on each unit for one of three units in the Woodcrest building. Specifically, 1) on 8/1/2023 on the Woodcrest 3 unit during the 7:00 AM-3:00 PM shift, 13 residents ( Resident #200, #358, #120, #341, #45, #639, #319, #210, #366, #241, #387, #303, #169) did not get there 9 AM medications within one hour of the physician-ordered administration time; [...]
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00299549) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident was free from any significant medication errors. This was identified for one (Resident #638) of one resident reviewed for significant medication errors. Specifically, on 7/18/2022 Resident #638 received two doses of Ambien (hypnotic for sleep which is a controlled substance), 10 milligrams each, for a total of 20 mg. The physician order documented a maximum daily dosage of one tablet (10 mg). The finding is: The facility's policy, titled Medication Administration, dated 5/14/2020, documented to promote medication safety, prevent medication errors, and to ensure that residents receive their prescribed medications in a timely and appropriate manner. [...]
Inspectors wroteBased on observation and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each controlled-substance storage box was separately locked as per the state and federal guidelines. This was identified for one of two medication carts on Seacliff 1 unit on 8/8/2023. Specifically, on 8/8/2023, a controlled substance box in a medication cart on Seacliff 1 unit did not have a lock. The unlocked box was observed with narcotic controlled substances. The finding is: The facility's policy, titled Medication Storage, dated 5/1/2021, documented all controlled substances, as defined by federal and state regulations, will be stored in a double-locked area within the medication cart or cabinet. The double locking will include both a locked drawer or compartment and a lock securing the medication cart or cabinet itself. [...]
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure outside services were provided to resident timely as per their Physician's orders. This was identified for one (Resident #97) of one resident reviewed for Psychotropic Medication Side Effects. Specifically, Resident #97, with a medical diagnosis of Parkinson's Disease was on a psychotropic medication, Zyprexa, as per their Physician's orders. A Physician's order for a Neurology consult due to increased shakiness was put in place on 5/12/2023. The resident has not been seen by the Neurologist as of 8/10/2023. The finding is: The facility's policy titled, Consults dated 2/21/2021 documented to provide residents with consultation services in accordance with their plan of care and as ordered by a physician. The physician will order the consult. [...]
Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside. This was identified 1) one (Resident #343) of eight residents reviewed for Activities of Daily Living (ADL) and 2) one (Resident #259) of three residents reviewed for the communication-sensory care area. Specifically, 1) On 8/1/2023, Resident #343's call light was wrapped over the head of the bed frame while the resident was in bed. The call bell was not in view or within reach of the resident. [...]
Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that a thorough investigation was conducted for one of three residents reviewed for accidents. Specifically, Resident #471 had two Accidents/Incident (A/I) reports with injuries without an investigation to determine whether the call bell was functioning, was within the resident's reach, and if the call bell was activated prior to the incident. The finding is: The Facility Policy titled Abuse Prevention Program Policy and Procedure dated 12/2017 documented it is the policy of the facility that all reports or allegations of abuse, mistreatment, neglect and/or misappropriation of resident belongings be promptly and thoroughly investigated. Resident # 471 was admitted with diagnosis that include Schizophrenia. [...]
Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 5/24/2021 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 #12) of two residents reviewed for Behavior and for one (Resident #279) of one resident reviewed for Urinary Tract Infections (UTI). Specifically, 1) Resident #12, who had a history of accusatory behavior, did not have a CCP developed addressing the need for a two person approach during care 2) Resident # 279 did not have a CCP developed for the use of an Antibiotic to treat a UTI.
Inspectors wroteBased on observation, record review, and interview during a Recertification Survey completed on 5/24/2021 the facility did not ensure that for one (Resident #360) of four residents reviewed for medication administration, the Licensed Practical Nurse (LPN) #3 followed the Physician's order as written. Specifically, the LPN crushed the medication Clozaril (Antipsychotic) 100 milligrams (mg) two tablets and placed the crushed medication in Resident #360's food without a Physician's order to crush the medication. The finding is: Resident #360 was admitted to the facility with a diagnoses that include Schizophrenia and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also documented that the resident had delusions. [...]
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure the resident environment remains free of accident hazards. This was identified for 2 of 3 residents reviewed for accidents. Specifically, 1) Resident # 249, who was identified as an elopement risk and wore a wander guard, entered an elevator and was able to reach the facility lobby on 1/23/2021. The elevator door did not function as intended with the use of the wander guard. The Registered Nurse Supervisor (RNS) did not report the elevator door malfunction. Subsequently, on 3/1/2021 Resident #249 entered the elevator and was able to reach the facility lobby again. 2) Resident #36 was using a wheelchair with a broken removable right arm rest which was identified on 5/21/2020 and was not addressed by the facility staff until 5/24/2021.
Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that each resident is free from unnecessary medications. This was identified for one (Resident #60) of five residents reviewed for unnecessary medications. Specifically, Resident #60 was prescribed Haldol (an antipsychotic medication), which was increased from 10 milligrams (mg) twice daily to 20 mg twice daily without documented evidence of the justification for the increase of the Haldol. The finding is: Resident #60 has diagnoses that include Dementia superimposed on Schizoaffective Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. [...]
Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that outside professional services were furnished in a timely manner for one (Resident #472) of 5 residents reviewed for unnecessary medications. Specifically, Resident #472 had a Physician's order for a Psychiatry consult dated 4/25/2021 and the Psychiatry consult was not completed as of 5/24/2021. The findings is: Resident #472 was admitted on [DATE] and readmitted on [DATE] with diagnosis including Dementia with Behavioral Disturbances. A Progress Notes dated 4/25/2021 at 2:38 PM , written by the Nurse Practitioner (NP) documented the NP was asked to see resident for behavior, and that the resident placed themselves on the ground and was laying on ground refusing to get up. [...]
Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure that each resident was offered Influenza and Pneumococcal vaccination and that each resident's medical record documented whether or not the resident received the immunization. This was identified for 1 (Resident # 13) of 5 residents reviewed for Influenza and Pneumococcal immunizations. Specifically, Resident #13's medical record lacked documented evidence of whether the resident received or declined the Influenza and Pneumococcal vaccines. The finding is: The facility's undated policy titled Conducting the Vaccination Program documented within 5 days of Admission/readmission the admitting nurse will complete the admission vaccine assessment, noting the resident's Influenza/Pneumococcal vaccine status. [...]
36 fire safety citations on file: 12 on October 23, 2024, 20 on August 10, 2023, 4 on May 24, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| February 12, 2024 | Fine | $117,712 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | New York | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.49 | 3.63 | 3.86 |
| Registered nurses | 0.67 | 0.71 | 0.69 |
| All nursing staff on weekends | 3.30 | 3.18 | 3.42 |
| Nurse aides | 2.13 | ||
| Licensed practical nurses | 0.69 | ||
| Nursing staff turnover (share who left in a year) | 44.7% | 40.3% | 45.8% |
| Registered nurse turnover | 54.4% | 39.8% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.58 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.57 on weekdays and 3.30 on weekends, 8% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.27 in April to June 2025 to 3.49 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.49 | 0.67 | 3.57 | 3.30 | 0.0% | 0 of 90 | 278 |
| Oct to Dec 2025 | 3.61 | 0.61 | 3.68 | 3.46 | 0.0% | 0 of 92 | 248 |
| Jul to Sep 2025 | 4.21 | 0.69 | 4.39 | 3.76 | 0.1% | 0 of 92 | 215 |
| Apr to Jun 2025 | 4.27 | 0.60 | 4.50 | 3.71 | 0.0% | 0 of 91 | 187 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| New York, Jan to Mar 2026 | 3.55 | 0.68 | 3.72 | 3.13 | 9.8% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| New York, all employers | |||
| CNAs (nursing assistants) | $23.36 | $21.04 to $24.99 | 87,990 |
| LPNs and LVNs | $32.30 | $29.52 to $37.00 | 39,400 |
| Registered nurses | $52.62 | $45.60 to $62.34 | 205,810 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | New York | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.1 | 14.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.0 | 1.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.2 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.0 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 6.3 | 12.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.5 | 6.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 18.9 | 13.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 17.2 | 20.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 3.2 | 9.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 1.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Woodbury Heights Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (43.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
43.9% this home
No different from the national rate
US median of homes 51.5% · New York: 101 better, 157 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 274 eligible stays.
11.1% this home
No different from the national rate
US median of homes 10.7% · New York: 12 better, 5 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 335 eligible stays.
7.1% this home
No different from the national rate
US median of homes 7.1% · New York: 7 better, 21 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 151 eligible stays.
52.8% this home
Median of homes: New York60.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 89 residents counted.
0.8% this home
Median of homes: New York0.6% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 122 residents counted.
5.6% this home
Median of homes: New York2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 122 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: New York98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 10 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: COLD SPRING ACQUISITION LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| David, Rochel | 5% or greater direct ownership interest | Individual | 13% | 07/08/2014 |
| Farkowitz, Esther | 5% or greater direct ownership interest | Individual | 25% | 07/08/2014 |
| Friedman, Leah | 5% or greater direct ownership interest | Individual | 13% | 07/08/2014 |
| Leifer, Joel | 5% or greater direct ownership interest | Individual | 25% | 07/08/2014 |
| Philipson, Avi | 5% or greater direct ownership interest | Individual | 24% | 07/08/2014 |
| David, Rochel | Corporate officer | Individual | 07/08/2014 | |
| Farkowitz, Esther | Corporate officer | Individual | 07/08/2014 | |
| Friedman, Leah | Corporate officer | Individual | 07/08/2014 | |
| Leifer, Joel | Corporate officer | Individual | 07/08/2014 | |
| Philipson, Avi | Corporate officer | Individual | 07/08/2014 | |
| Simpser, Josef | Operational/managerial control | Individual | 11/01/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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