Inspection Reports for
Excel at Woodbury for Rehabilitation and Nursing, LLC

8533 Jericho Tpke, Woodbury, NY, 11797

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Citations (last 4 years)

Citations (over 4 years) 8.3 citations/year

Citations are regulatory findings recorded during state inspections.

63% worse than New York average
New York average: 5.1 citations/year

Citations per year

24 18 12 6 0
2022
2023
2024
2025

Inspection Report

Annual Inspection
Capacity: 60 Citations: 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.

Citations (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

Complaint Investigation
Capacity: 60 Citations: 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.

Citations (4)
Develop/implement comprehensive care plan
Free from abuse and neglect
Label/store drugs and biologicals
Cooking facilities

Inspection Report

Annual Inspection
Citations: 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.

Citations (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
NameTitleContext
Licensed Practical Nurse #1Observed medication pass and acknowledged discrepancy between medication labels and physician orders.
Registered Nurse Supervisor #1Interviewed regarding medication labeling discrepancies and facility procedures.
Certified Nurse Aide #7Witnessed and reported the resident-to-resident altercation between Resident #310 and Resident #311.
Registered Nurse Supervisor #5Responded to the resident altercation incident and interviewed about the event.
Director of Nursing ServicesInterviewed multiple times regarding the abuse incident and care plan deficiencies.
Director of Social WorkInterviewed regarding Resident #311's behavioral issues and care needs.
Certified Nursing Assistant #2Reported Resident #16's behavior of removing the hip abduction flexion contracture cushion.
Registered Nurse #4Unit ManagerInterviewed about notification procedures related to Resident #16's refusal of assistive device.
Physical Therapist #1Interviewed regarding Resident #16's therapy and use of hip abduction flexion contracture cushion.

Inspection Report

Annual Inspection
Citations: 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 Citations: 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.

Citations (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
Citations: 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.

Citations (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
NameTitleContext
RN #1Registered NurseEntered medication orders and performed Pleurx catheter drainage treatments
RN #6Registered NurseClarified medication dosage with psychiatrist but did not notify resident's designated representative
Director of Nursing ServicesDirector of Nursing ServicesInterviewed regarding notification policies, abuse investigation, care planning, and treatment administration
CNA #4Certified Nursing AssistantAssigned to Resident #187 but not interviewed during abuse investigation
LPN #1Licensed Practical NurseDocumented Pleurx catheter treatments not administered on 11/8/2021
RN #2Inservice Coordinator and Infection PreventionistInterviewed about Pleurx catheter drainage documentation and procedures
RN #4Corporate EducatorProvided inservice training for Pleurx catheter drainage
Director of MaintenanceDirector of MaintenanceInterviewed regarding facility cleanliness and pest control

Inspection Report

Capacity: 60 Citations: 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.

Citations (1)
Reporting - national health safety network

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