Excel At Woodbury for Rehabilitation and Nursing,

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; and 2) Resident #64 had a Physician Order for an Ace wrap (a compression or elastic bandage that provides support and compression to an area of the body) to lower legs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The finding is:The facility's undated policy titled Storage of Medications documented that compartments containing drugs shall be locked when not in use. These include drawers, cabinets, refrigerators, carts,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. On 7/3/2023 Resident #310 punched Resident #311 on the face. Resident #310 stated they hit Resident #311 because they (Resident #311) used foul language toward…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: The facility's policy titled, Assistive Devices last revised 11/2022 documented nursing staff is responsible for ensuring the wearing schedule for assistive devices is followed. Conduct skin inspection at a minimum every shift unless otherwise ordered. Nursing or any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: The facility's policy titled, Pharmacy, dated June 2018, documented the facility utilizes its pharmaceutical services system to ensure the safe and effective use of medications for all our residents; this facility does not have an in-house pharmacy; this facility uses a blister pack system; Medications no longer in use shall be returned for credit or destroyed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. (2) In the Central Supply closet on the A Wing, plastic bottles, a box of q- tips, and litter was observed on the floor and underneath the metal storage racks (3) In the Staff Lounge, litter was observed behind and along the sides of the refrigerator (4) In the Kitchen, the corners on the floor near the range contained a build-up food, litter, and unknown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Resident #59 stated that the facility has had a lot of bugs like cockroaches and that there were mice in the facility. Resident #59 further stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: The facility's policy titled, Notification of Family of Resident Status Change dated 8/25/2021 documented that it was the policy of the facility to inform the DR of any changes in the resident's condition/status and implemented interventions (If applicable). Residents with a Brief Interview for Mental Status (BIMS) of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: The facility Accident and Incident Reporting Policy dated 12/1/2019 documented that when an incident occurs to a resident, it will be documented in an Accident Incident Report and an internal investigation will be conducted to determine the root cause of the accident/incident. The facility Resident Abuse, Mistreatment, Neglect and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: The facility's policy titled, Comprehensive Care Plans (CCP) and Resident/Patient Meeting dated 11/27/2017 documented that a comprehensive assessment for resident's needs shall be prepared within 14 days from admission and a CCP developed within 21 days from admission. The policy also documented that information obtained from the comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. There was no documentation in the medical record regarding the treatment was not administered or that the physician was notified. Furthermore, on two occasions when the Pleurx catheter was drained, there was no documentation of the amount of fluid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.