Woodcrest Rehabilitation & Residential Health Care

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident in 2 (Resident #150 and #85) of 4 residents reviewed for Rehabilitation and Restorative Care. Specifically, 1.) Resident #150 was observed without hand rolls and no knee abductor cushion in place that were ordered for the use and prevention of increased contractures of the bilateral upper and lower extremities. 2.) Resident #85 was observed without hand rolls in place as ordered by the physician.

Inspectors wroteBased on observation, record review, and interviews, during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 (Resident #150) of 35 total sampled residents. Specifically, Resident #150, who had a physician's order to use a mouth guard in the morning, was observed without a mouth guard applied on 2 occasions.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure a resident received care, consistent with professional standards of practice to prevent pressure ulcers. This was evident for 1 (Resident #150) of 3 residents reviewed for Pressure Ulcers. Specifically, Resident #150, who was at high risk to develop pressure ulcer and had physician's order for bilateral heel booties while in bed, was observed on 2 occasions in bed without heel booties.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 07/01/2025 to 07/09/2025, the facility did not ensure that residents are free of any significant medication errors. This was evident for 1 (Resident #46) out 7 residents sampled during the Medication Administration Task. Specifically, Resident #46 was not administered 8 milliliters of Levetiracetam 100 milligram/milliliters by oral route for seizures as ordered by the physician.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #9) of 37 total sampled residents. Specifically, Registered Nurse #4 failed to practice hand hygiene during wound care.

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00347821, NY00348092 and NY00354868), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency). [...]

Inspectors wroteBased on record review and interviews during the recertification survey from 2/2/23 to 2/9/23, the facility did not ensure the surety bond provided security of all personal funds of residents deposited with the facility. This was evident for 122 of 194 residents with personal needs accounts (PNA) with the facility. Specifically, the facility's surety bond was less than the total amount from 122 PNAs maintained by the facility.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 2/2/23 to 2/9/23, the facility did not ensure Housekeeping and Maintenance services maintained a sanitary, orderly, and comfortable interior. This was evident on 2 (Unit 4 and 5) of 5 units. Specifically, 1) Unit 5 was observed with multiple environmental concerns throughout the unit including furniture in disrepair, dirty floors, dust, rust, and stains in resident rooms and the common areas, and 2) Unit 4 was observed with peeling paint, rusty areas, a broken closet door, and equipment in disrepair.

Inspectors wroteBased on interviews and record review conducted during the Recertification and Complaint Survey (NY00305874) from 2/2/23 to 2/9/23, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the New York State Department of Health (NYSDOH). This was evident for 3 resident-to-resident altercations involving 4 (Resident # 402, # 145, # 37 and # 97) out of 4 residents reviewed for Abuse. Specifically, 1) the facility did not report to NYSDOH after Resident #402 hit Resident #145, 2) the facility did not report to NYSDOH after Resident #402 hit Resident #37, and 3) the facility did not report to NYSDOH after Resident #402 hit Resident #97.

Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey from 2/2/23 to 2/9/23, the facility did not ensure quarterly financial records were made available to a resident's representative. This was evident for 1 (Resident #78) of 1 resident(s) Personal Funds review. Specifically, Resident #78's designated representative (DR) did not receive quarterly statements of the resident's Personal Needs Account (PNA).

Inspectors wroteBased on interviews and record review conducted during Recertification and Complaint (NY00305874) Survey from 2/2/23 to 2/9/23, the facility did not ensure residents were free from abuse. This was evident for 2 (Resident #37 and Resident #97) of 4 residents reviewed for Abuse. Specifically, Residents #37 and #97 were victims of resident-to-resident abuse from Resident #402, a resident with Dementia, aggression and a history of a previous altercation with Resident #145. The facility did not implement new interventions for Resident #402 after each incident of resident-to-resident abuse to prevent additional altercations.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in timely. This was evident for 2 (Resident #37 and #15) of 2 residents reviewed for Resident Assessment of a sample of 38 residents. Specifically, 1) Resident #37's quarterly and significant change MDS were submitted more than 14 days after completion, and 2) Resident #15's quarterly MDS assessments were submitted more than 14 days after completion.

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not ensure that the residents' call bell system was maintained in proper working order. This was evident for 1 (Resident #76) of 9 residents reviewed for the environment. Specifically, Resident #76's call bell and light did not work when they were activated by the surveyor.

Inspectors wroteBased on record review and interview during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, quarterly assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date, and comprehensive assessments were not submitted within 14 days of the care plan completion dated. This is evident for 7 of 12 residents reviewed for the Resident Assessment facility task (Resident #s 2, 13, 4, 45, 8, 10, and 40).

Inspectors wroteBased on record review and interviews during the re-certification survey, the facility did not ensure residents comprehensive care plans (CCP) were developed and implemented to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, (1) Resident #165 did not have a CCP in place to address contact precautions for Carbapenem-Resistant Enterobacteriaceae (CRE) Pseudomonas in the urine, and (2) Resident #187 did not have a CCP in place to address that the resident was prescribed to use bilateral hand rolls. This was evident in 2 residents out of a final sample of 38 residents (Resident #165 and #187).

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. Specifically, a resident who is hard of hearing did not receive a hearing aid evaluation, annual audiology exam, and ENT (Ear, Nose, and Throat) follow-up for cerumen removal as recommended by the ENT. This was evident for 1 of 1 resident reviewed for Vision/Hearing (Resident#213).

Inspectors wroteBased on observations, record reviews, and interviews during the re-certification survey, the facility did not ensure residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, (1) a resident did not have a right hand splint in place, as ordered; and (2) a resident did not have bilateral hand rolls in place, as ordered. This was evident in 2 of 5 residents reviewed for limited range of motion out of a total sample of 38 residents (Resident #113 and #187). The finding is. The facility policy and procedure titled, Splints and Braces (Dated 11/19) documented the following: .the splinting program is initiated by occupational therapy .the splinting program is noted in resident care plan when the occupational therapist has determined the fit and wearing time for the splint . [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure that the physician reviewed the resident's total program of care. Specifically, the physician did not follow-up on a resident's ENT (Ear, Nose, and Throat) recommendations for a hearing aid evaluation, annual audiology exam, and ENT follow-up for cerumen removal. This was evident for 1 of 1 resident reviewed for Vision/Hearing (Resident#213).

Inspectors wroteBased on observation, record review, and interviews during the re-certification survey, the facility did not ensure infection control practices were maintained to help prevent the development and transmission of communicable diseases and infections. Specifically, a staff member was observed entering the room of a resident on contact precautions for Carbapenem-Resistant Enterobacteriaceae (CRE) Pseudomonas in the urine without donning Personal Protective Equipment (PPE) (Resident #165). This was evident for 1 of 5 resident floors observed for Infection Control (2nd Floor). The finding is: The facility policy and procedure titled, Contact Precautions (Dated 11/01/2019) was reviewed. Contact precautions are to be used for specific residents known to be infected that can be transmitted with indirect contact with environmental surfaces or resident care items in the resident's environment. [...]