Inspection Reports for
White Oaks Rehabilitation and Nursing Center
8565 Jericho Turnpike, Woodbury, NY, 11797
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
20.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
306% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The abbreviated survey was conducted to investigate compliance with care and safety standards, specifically focusing on an incident involving a resident's injury during transfer.
Findings
The facility failed to ensure Resident #1 was free from accidents by not following the care plan requiring a two-person assist during transfers. This failure resulted in a fractured left humerus and actual harm to the resident.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. Certified Nursing Assistant #1 transferred Resident #1 alone despite orders for a two-person assist, causing a fractured left humerus.
Report Facts
Residents affected: 1
Date of injury: Sep 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in transfer incident causing resident injury | |
| Licensed Practical Nurse Risk Manager | Conducted investigation and interviews related to the injury | |
| Director of Nursing | Reviewed care plan and instructed removal of Certified Nursing Assistant #1 pending investigation | |
| Medical Doctor #1 | Ordered x-ray and assessed resident injury |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Sep 8, 2025
Visit Reason
Complaint Survey with 7 standard health citations and 0 life safety code citations.
Findings
Complaint Survey with 7 standard health citations and 0 life safety code citations.
Deficiencies (7)
Facility assessment
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection prevention & control
Posted nurse staffing information
Respiratory/tracheostomy care and suctioning
Right to be free from physical restraints
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 8, 2025
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home operations, including resident care, safety, staffing, infection control, and food service.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, inadequate supervision and monitoring of residents at risk for accidents, failure to provide respiratory care consistent with physician orders, incomplete and inaccurate nursing staffing postings, improper food storage and temperature monitoring, inaccurate facility-wide staffing assessment, and lapses in infection prevention and control practices.
Deficiencies (7)
F 0604: The facility failed to ensure residents were free from physical restraints unless medically necessary, as Resident #36's bed was positioned to restrict movement, contrary to facility policy.
F 0689: The facility did not provide adequate supervision or interventions to prevent accidents, as Resident #12 removed their Wanderguard and staff failed to monitor or update care plans accordingly.
F 0695: The facility failed to provide respiratory care consistent with professional standards and physician orders, as Resident #129's oxygen saturation monitoring was discontinued without a physician's order.
F 0732: The facility did not post nursing staffing daily with actual hours worked by licensed and unlicensed staff per shift, violating staffing posting requirements.
F 0812: The facility failed to ensure food was stored, prepared, and served in accordance with professional standards, including undated frozen food items and failure to monitor cold food temperatures during meal service.
F 0838: The facility's Facility Assessment did not accurately document nursing staffing needs for day-to-day operations, specifically Registered Nurse coverage on certain shifts and units.
F 0880: The facility failed to maintain an effective infection prevention and control program, as staff did not perform hand hygiene or use appropriate personal protective equipment during wound care and contact isolation precautions.
Report Facts
Residents reviewed for Physical Restraints: 1
Residents reviewed for Accidents: 5
Residents reviewed for Respiratory Care: 3
Residents reviewed for Transmission-Based Precautions: 3
Temperature of cold food items: 60
Temperature of cold food items: 59
Temperature of cold food items: 42.1
Temperature of cold food items: 50.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #5 | Acknowledged placing Resident #36's bed to restrict movement | |
| Registered Nurse Charge Nurse #1 | Charge Nurse | Provided statements regarding Wanderguard monitoring and oxygen saturation monitoring |
| Licensed Practical Nurse #2 | Medication Nurse | Did not check Wanderguard placement during medication administration |
| Physical Therapist #1 | Physical Therapist | Recommended fall prevention interventions for Resident #36 |
| Staffing Coordinator | Responsible for preparing nursing staffing sheets | |
| Director of Nursing Services | Director of Nursing Services | Provided multiple statements on restraint policy, staffing, and infection control |
| Food Service Director | Provided statements on food storage and temperature monitoring | |
| Licensed Practical Nurse #1 | Performed wound care improperly without hand hygiene | |
| Registered Nurse Wound Care Nurse #1 | Wound Care Nurse | Provided expert statements on wound care procedures |
| Certified Nursing Assistant #2 | Entered Resident #111's room without PPE and failed hand hygiene | |
| Registered Nurse #1 | Unit Manager | Provided statements on infection control and PPE use |
| Licensed Practical Nurse Infection Preventionist #1 | Infection Preventionist | Provided statements on infection control expectations |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 9, 2024
Visit Reason
The survey was a Recertification Survey conducted from 3/4/2024 to 3/9/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to timely report injuries of unknown origin, incomplete investigations of alleged abuse, incomplete baseline and comprehensive care plans, improper medication administration practices, inadequate personal hygiene care, failure to apply physician-ordered devices, unsafe medication storage and reconciliation, and insufficient staffing in food service leading to use of disposable dinnerware.
Deficiencies (10)
F 0609: The facility failed to timely report injuries of unknown origin to the New York State Department of Health and did not thoroughly investigate incidents to identify root causes and rule out abuse or neglect for Resident #119.
F 0610: The facility failed to respond appropriately to all alleged violations, including incomplete investigations and missing staff statements related to injuries of unknown origin for Resident #119.
F 0655: The facility did not develop a baseline care plan within 48 hours of admission for Resident #78 who was admitted with impaired skin integrity and a pressure ulcer.
F 0657: The facility failed to update comprehensive care plans to reflect current needs, including off-loading devices for pressure ulcers for Resident #78 and compression wraps for edema for Resident #171.
F 0658: The facility failed to ensure services met professional standards, including administering medication from another resident's supply to Resident #169.
F 0677: The facility failed to provide necessary assistance for activities of daily living, as Resident #56 was observed with long, unclean fingernails despite care plans and physician orders.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion, as Residents #56 and #36 were observed not wearing physician-ordered hand rolls.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision, as Resident #167 was observed with physician-ordered medication unsecured in their room.
F 0755: The facility failed to provide pharmaceutical services meeting professional standards, including improper medication reordering and borrowing of medications, and inaccurate controlled substance record reconciliation.
F 0802: The facility did not provide sufficient support personnel to safely and effectively carry out food and nutrition services, resulting in use of disposable dinnerware on weekends due to kitchen staffing shortages.
Report Facts
Deficiencies cited: 10
Medication tablets: 11
Medication tablets: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Responded to injury of Resident #119 and provided inconsistent statements about incident. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Assigned to Resident #119 during injury incident and interviewed about observations. |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Assigned 1:1 to Resident #119 and observed bruises on 2/29/2024. |
| Registered Nurse #5 | Registered Nurse | Unit charge nurse who assessed Resident #119's bruises and initiated incident report. |
| Registered Nurse #4 | Registered Nurse | Administered borrowed medication to Resident #169 and interviewed about medication practices. |
| Director of Nursing Services | Director of Nursing | Interviewed multiple times regarding deficiencies and facility practices. |
| Food Service Director | Food Service Director | Interviewed about use of disposable dinnerware due to kitchen staffing shortages. |
| Dietary Aide #1 | Dietary Aide | Interviewed about kitchen staffing and use of disposable dinnerware on 3/4/2024. |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Observed Resident #56's untrimmed nails and aware of bruise on Resident #20 but did not report. |
| Registered Nurse #3 | Registered Nurse | Unit Manager interviewed about responsibilities for nail care and hand roll application. |
| Physician #2 | Physician | Resident's assigned physician interviewed about hand roll and medication application. |
| Physical Therapist #1 | Physical Therapist | Interviewed about hand roll recommendation and importance. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 18
Date: Mar 9, 2024
Visit Reason
Complaint Survey with 11 standard health citations and 5 life safety code citations, all deficiencies corrected as of May 1, 2024.
Findings
Complaint Survey with 11 standard health citations and 5 life safety code citations, all deficiencies corrected as of May 1, 2024.
Deficiencies (18)
ADL care provided for dependent residents
Baseline care plan
Care plan timing and revision
Competent nursing staff
Free of accident hazards/supervision/devices
Increase/prevent decrease in rom/mobility
Investigate/prevent/correct alleged violation
Pharmacy srvcs/procedures/pharmacist/records
Reporting of alleged violations
Services provided meet professional standards
Sufficient dietary support personnel
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Maintenance, inspection & testing - doors
Organization and administration
Fire alarm system - installation
Fire alarm system - testing and maintenance
Fire drills
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 30, 2022
Visit Reason
Covid-19 Survey with 1 standard health citation related to reporting to national health safety network.
Findings
Covid-19 Survey with 1 standard health citation related to reporting to national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Apr 13, 2022
Visit Reason
Complaint Survey with 5 standard health citations and 8 life safety code citations, all corrected as of June 8, 2022 except fire drills.
Findings
Complaint Survey with 5 standard health citations and 8 life safety code citations, all corrected as of June 8, 2022 except fire drills.
Deficiencies (13)
Competent nursing staff
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Resident self-admin meds-clinically approp
Tube feeding mgmt/restore eating skills
Cooking facilities
Electrical systems - essential electric syste
Fire alarm system - installation
Fire alarm system - testing and maintenance
Fire drills
Interior wall and ceiling finish
Means of egress - general
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 6, 2022
Visit Reason
The inspection was a Recertification Survey conducted from April 6, 2022 to April 13, 2022 to assess compliance with regulatory requirements for White Oaks Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to ensure proper assessment and documentation for residents self-administering medications, incomplete comprehensive care plans for residents with Foley catheters, unsafe resident environment with unsecured hazardous items, improper care and supervision related to feeding tubes, and inadequate staff competency in tube feeding procedures.
Deficiencies (5)
F 0554: The facility did not ensure the interdisciplinary team determined clinical appropriateness for residents self-administering medications. Resident #113 self-administered nasal spray without documented assessment or physician order to keep medication bedside.
F 0656: The facility failed to develop a comprehensive care plan for Resident #137's indwelling Foley catheter use, despite baseline care plan documentation and physician orders.
F 0689: The facility did not ensure a resident's environment was free from accident hazards. Resident #115 had an unlocked drawer containing scissors, screwdriver, and discontinued medication, posing safety risks.
F 0693: The facility failed to ensure appropriate care for a resident with a feeding tube. Resident #13 was observed lying flat while tube feeding was running, increasing aspiration risk.
F 0726: The facility did not ensure nurse aides demonstrated competency in tube feeding care. CNA #1 provided care to Resident #13 while tube feeding was running and resident was lying flat, contrary to training.
Report Facts
Residents reviewed for Accidents: 8
Residents reviewed for Urinary catheter use: 2
Residents with wandering behavior: 4
Tube feeding rate: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Present during observation of Resident #113 self-administering medication; documented medication non-compliance. | |
| Registered Nurse (RN) #1 | Observed Resident #113 self-administering medication; interviewed about medication orders. | |
| Director of Nursing Services (DNS) | Interviewed regarding medication self-administration policies and care plan deficiencies. | |
| Registered Nurse (RN) #2 | Unit manager interviewed about urinary catheter diagnosis and care planning for Resident #137. | |
| Director of Social Work (DSW) | Interviewed regarding Resident #115's possession of hazardous items and family education. | |
| Attending Physician #1 | Interviewed about Resident #115's medication and safety concerns. | |
| Certified Nursing Assistant (CNA) #1 | Observed providing care to Resident #13 during tube feeding; unaware feeding was running. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about communication with CNA #1 regarding tube feeding pause. | |
| Nurse Practitioner (NP) #4 | Interviewed about tube feeding protocols and aspiration risk. |
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