Inspection Reports for
Excel at Woodbury for Rehabilitation and Nursing, LLC
8533 Jericho Tpke, Woodbury, NY, 11797
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 5
Date: Jul 22, 2025
Visit Reason
Certification Survey found multiple Level 1 and Level 2 deficiencies related to comprehensive assessments, care plans, resident assessments, drug labeling, and smoke barrier subdivision. All deficiencies were corrected by September 10, 2025.
Findings
Certification Survey found multiple Level 1 and Level 2 deficiencies related to comprehensive assessments, care plans, resident assessments, drug labeling, and smoke barrier subdivision. All deficiencies were corrected by September 10, 2025.
Deficiencies (5)
Comprehensive assessments & timing
Develop/implement comprehensive care plan
Encoding/transmitting resident assessments
Label/store drugs and biologicals
Subdivision of building spaces - smoke barrier
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 22, 2025
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home resident assessments, care planning, medication storage, and transmission of Minimum Data Set assessments.
Findings
The facility failed to complete comprehensive resident assessments timely, did not transmit Minimum Data Set assessments within required timeframes, lacked comprehensive care plans for certain residents' conditions, and failed to ensure drugs and biologicals were stored securely and labeled properly.
Deficiencies (4)
F0636: The facility did not complete Resident #44's Annual Minimum Data Set assessment within the required 14 days after the Assessment Reference Date, completing it 27 days late.
F0640: The facility failed to transmit Resident #44's Minimum Data Set assessments to CMS within 14 days of completion, including Quarterly, Annual, and Significant Change assessments, with some transmitted late and one not transmitted at all.
F0656: The facility did not develop comprehensive care plans with measurable objectives for Resident #82's possible Melanoma and Resident #64's Lymphedema and use of Ace wraps/compression stockings.
F0761: The facility did not ensure drugs and biologicals were stored in locked compartments; Resident #7 had discontinued Lidocaine ointment and unlabeled glucose tablets stored unsecured in their room.
Report Facts
Days late for assessment completion: 27
Days late for assessment transmission: 30
Assessment transmission delay: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Unit Manager | Stated no current order or care plan for Resident #82's dressing and skin lesions; monitored possible Melanoma. |
| Registered Nurse #3 | Unit Manager | Stated no knowledge of who put dressing on Resident #82's head. |
| Physician #1 | Documented possible Melanoma diagnosis and ordered dermatology consultation for Resident #82. | |
| Licensed Practical Nurse #1 | Applied dry dressing on Resident #82's head per resident request without order or progress note. | |
| Assistant Director of Nursing Services | Medication Nurse | Stated Resident #7 should not have medications stored in room; Lidocaine ointment discontinued. |
| Director of Nursing Services | Stated staff should be observant of medications in resident rooms and that Resident #7 should not have medications stored without assessment. | |
| Registered Nurse #1 | Unit Manager | Stated no care plan for Resident #64's Lymphedema and use of Ace wrap or compression stockings. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Apr 23, 2024
Visit Reason
Complaint Survey identified Level 2 deficiencies in care plan development, abuse prevention, drug labeling, and cooking facilities. All issues were corrected by May 2024.
Findings
Complaint Survey identified Level 2 deficiencies in care plan development, abuse prevention, drug labeling, and cooking facilities. All issues were corrected by May 2024.
Deficiencies (4)
Develop/implement comprehensive care plan
Free from abuse and neglect
Label/store drugs and biologicals
Cooking facilities
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey triggered by Complaint #NY00319453 regarding alleged resident abuse.
Complaint Details
Complaint #NY00319453 was investigated. The incident involved a resident-to-resident altercation where Resident #310 punched Resident #311. The investigation concluded that abuse did occur. The Director of Nursing Services initially misreported the incident but later confirmed it as abuse when reporting to the New York State Department of Health.
Findings
The facility failed to ensure resident rights to be free from abuse when Resident #310 punched Resident #311 during a resident-to-resident altercation on 7/3/2023, resulting in physical injury to Resident #311. The Director of Nursing Services later confirmed the incident constituted abuse.
Deficiencies (1)
F 0600: The facility did not protect residents from abuse as Resident #310 punched Resident #311 causing a three-centimeter linear scratch and an open area to the right upper ear. The incident was initially misclassified but later confirmed as abuse by the Director of Nursing Services.
Report Facts
Date of incident: Jul 3, 2023
Length of scratch: 3
Medication dosage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #7 | Witnessed and reported the altercation between Resident #310 and Resident #311 | |
| Registered Nurse Supervisor #5 | Responded to the incident and interviewed regarding the altercation | |
| Director of Nursing Services | Interviewed and confirmed the incident as abuse | |
| Director of Social Work | Interviewed regarding Resident #311's behavioral history and difficulties with redirection |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey including a complaint investigation related to resident abuse and compliance with care planning and medication administration.
Complaint Details
The complaint investigation involved an alleged resident-to-resident abuse incident between Resident #310 and Resident #311. The investigation found that Resident #310 did intentionally punch Resident #311, resulting in injury. The Director of Nursing Services confirmed the incident constituted abuse.
Findings
The facility was found to have failed to protect residents from abuse in a resident-to-resident altercation, did not implement a comprehensive person-centered care plan with measurable objectives for positioning and mobility, and did not ensure medications were labeled in accordance with physician orders and professional principles.
Deficiencies (3)
F 0600: The facility failed to protect residents from abuse when Resident #310 punched Resident #311 causing injury. The investigation initially concluded no abuse, but the Director of Nursing later confirmed the incident was abuse.
F 0656: The facility did not implement a complete care plan for Resident #16 requiring a hip abduction flexion contracture cushion, as the resident was observed not wearing the device on multiple occasions.
F 0761: The facility failed to ensure drugs and biologicals were labeled according to physician orders. Medication blister pack labels for Resident #312 did not match physician orders for Allopurinol and Torsemide.
Report Facts
Deficiencies cited: 3
Injury size: 3
Medication dosage: 200
Medication dosage: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Observed medication pass and acknowledged discrepancy between medication labels and physician orders. | |
| Registered Nurse Supervisor #1 | Interviewed regarding medication labeling discrepancies and facility procedures. | |
| Certified Nurse Aide #7 | Witnessed and reported the resident-to-resident altercation between Resident #310 and Resident #311. | |
| Registered Nurse Supervisor #5 | Responded to the resident altercation incident and interviewed about the event. | |
| Director of Nursing Services | Interviewed multiple times regarding the abuse incident and care plan deficiencies. | |
| Director of Social Work | Interviewed regarding Resident #311's behavioral issues and care needs. | |
| Certified Nursing Assistant #2 | Reported Resident #16's behavior of removing the hip abduction flexion contracture cushion. | |
| Registered Nurse #4 | Unit Manager | Interviewed about notification procedures related to Resident #16's refusal of assistive device. |
| Physical Therapist #1 | Interviewed regarding Resident #16's therapy and use of hip abduction flexion contracture cushion. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
Annual inspection survey of Excel at Woodbury for Rehab and Nursing facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Sep 22, 2022
Visit Reason
Complaint Survey revealed multiple Level 2 deficiencies including care plan development, violation investigation, pest control, notification of changes, quality of care, provider responsibilities, environment, and various life safety code issues. All deficiencies were corrected by late 2022.
Findings
Complaint Survey revealed multiple Level 2 deficiencies including care plan development, violation investigation, pest control, notification of changes, quality of care, provider responsibilities, environment, and various life safety code issues. All deficiencies were corrected by late 2022.
Deficiencies (14)
Develop/implement comprehensive care plan
Investigate/prevent/correct alleged violation
Maintains effective pest control program
Notify of changes (injury/decline/room, etc.)
Quality of care
Responsibilities of providers; required notification
Safe/functional/sanitary/comfortable environment
Development of communication plan
Electrical systems - essential electric system
Gas equipment - cylinder and container storage
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrier
Subsistence needs for staff and patients
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 22, 2022
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey conducted from 9/18/2022 to 9/22/2022, including complaint investigations related to medication notification, abuse investigation, care planning, treatment administration, and environmental safety.
Complaint Details
The survey included complaint investigations regarding failure to notify family of medication changes (Resident #190), inadequate abuse investigation (Resident #187), and environmental concerns including pest control and sanitation.
Findings
The facility failed to notify the resident's designated representative of medication changes, did not thoroughly investigate an abuse allegation, lacked a comprehensive care plan for diabetes management, failed to administer and document Pleurx catheter treatments properly, and did not maintain a safe, sanitary, and pest-free environment.
Deficiencies (6)
F 0580: The facility did not notify Resident #190's designated representative when medication changes were made, including Zoloft dosage increase and initiation of Remeron.
F 0610: The facility failed to thoroughly investigate an abuse allegation for Resident #187, omitting statements from the assigned CNA and not including the resident's direct statement in the investigation summary.
F 0656: Resident #190 did not have a comprehensive care plan addressing diabetes mellitus and blood sugar monitoring despite physician orders for finger sticks and insulin administration.
F 0684: Resident #189 did not receive ordered Pleurx catheter drainage treatment on 11/8/2021, and documentation of drainage amounts was incomplete on other dates.
F 0921: The facility environment was unsanitary with soiled floors, litter, sticky substances, and dust buildup in multiple areas including kitchen, storage, and utility rooms.
F 0925: The facility failed to maintain an effective pest control program, with observed bugs in the kitchen, storage room, and resident areas despite ongoing pest treatments.
Report Facts
Medication dosage increase date: Jan 7, 2022
Medication start date: Jan 4, 2022
Pleurx catheter drainage dates: 3
Pest control treatments: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Entered medication orders and performed Pleurx catheter drainage treatments |
| RN #6 | Registered Nurse | Clarified medication dosage with psychiatrist but did not notify resident's designated representative |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding notification policies, abuse investigation, care planning, and treatment administration |
| CNA #4 | Certified Nursing Assistant | Assigned to Resident #187 but not interviewed during abuse investigation |
| LPN #1 | Licensed Practical Nurse | Documented Pleurx catheter treatments not administered on 11/8/2021 |
| RN #2 | Inservice Coordinator and Infection Preventionist | Interviewed about Pleurx catheter drainage documentation and procedures |
| RN #4 | Corporate Educator | Provided inservice training for Pleurx catheter drainage |
| Director of Maintenance | Director of Maintenance | Interviewed regarding facility cleanliness and pest control |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 23, 2022
Visit Reason
Covid-19 Survey identified a Level 2 deficiency related to reporting to the national health safety network. No correction date noted.
Findings
Covid-19 Survey identified a Level 2 deficiency related to reporting to the national health safety network. No correction date noted.
Deficiencies (1)
Reporting - national health safety network
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