Inspection Reports for
Woodland Pond at New Paltz
200 Woodland Pond Circle, New Paltz, NY, 12561
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with care standards, focusing on activities of daily living assistance and staffing adequacy.
Findings
The facility failed to ensure timely assistance for residents unable to perform activities of daily living, resulting in long wait times for incontinence care and personal hygiene. Staffing levels were insufficient to meet resident needs, especially during night shifts, causing delays in care and resident complaints.
Deficiencies (2)
F 0677: The facility did not provide timely care and assistance for activities of daily living for residents unable to perform them independently, evidenced by residents waiting extended periods for incontinence care and personal hygiene.
F 0725: The facility failed to provide sufficient nursing staff daily to meet resident needs and have a licensed nurse in charge on each shift, resulting in long call bell response times and delayed care.
Report Facts
Call bell alarms over 30 minutes response: 196
Call bell alarms over 30 minutes response: 104
Call bell alarms over 30 minutes response: 178
Call bell alarms over 30 minutes response: 151
Call bell wait time: 66
Call bell wait time: 30
Residents requiring 2-person assistance: 19
Certified Nurse Aides assigned: 2
Certified Nurse Aides assigned: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #9 | Certified Nurse Aide | Assigned to Resident #6, reported inability to provide timely care due to workload |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Medication nurse who assisted aides and described staffing challenges |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Reported staffing levels and challenges during evening/night shifts |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing adequacy and call bell response monitoring |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from April 21, 2025 to April 24, 2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to notify residents of grievance officials and processes, inadequate assistance with activities of daily living resulting in long wait times for care, insufficient nursing staff to meet resident needs, improper food storage and handling practices, and lapses in infection prevention and control during medication administration.
Deficiencies (5)
F 0585: The facility did not ensure residents were notified of the grievance official or their right to receive written grievance decisions. Seven residents and a family representative were unaware of this information.
F 0677: The facility failed to provide timely assistance with activities of daily living for residents dependent on staff, including long wait times up to 66 minutes for incontinence care for Resident #28 and inconsistent care for Resident #6.
F 0725: The facility did not ensure sufficient nursing staff to meet resident needs, with documented long call bell response times and resident complaints of delayed care, particularly on night shifts with only two aides for 40 residents.
F 0812: Food was not stored or handled according to professional standards, including unlabeled and undated food items in the walk-in refrigerator and freezer, wet pots stacked improperly, and dietary staff not consistently wearing hair nets or beard covers.
F 0880: Infection prevention and control practices were not followed during medication administration. Licensed Practical Nurse #1 failed to perform hand hygiene appropriately and touched medication capsules with bare hands while administering eye drops and gastrostomy tube medications.
Report Facts
Call bell alarms exceeding 30 minutes response: 629
Wait time for incontinence care: 66
Residents requiring 2-person assistance: 19
Certified Nurse Aides on night shift: 2
Residents in night shift assignment: 40
Residents attending Resident Council meeting: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in infection control deficiency for failure to perform hand hygiene during medication administration |
| Certified Nurse Aide #9 | Certified Nurse Aide | Named in deficiency related to delayed assistance with activities of daily living for Resident #6 |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing adequacy and infection control practices |
| Administrator | Administrator | Interviewed regarding grievance process and staffing |
| Dining Manager #5 | Dining Manager | Named in food service deficiency for not wearing hair net while serving food |
| Assistant Director of Dining #6 | Assistant Director of Dining | Named in food service deficiency for responsibility of food dating and storage |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 3, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Woodland Pond at New Paltz.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 28, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory standards for nursing home operations, including medication storage, food safety, infection control, water management, and facility safety.
Findings
The facility had multiple deficiencies including improper medication refrigerator temperature control, expired and improperly stored food items, inadequate water management with repeated Legionella contamination, failure to perform proper hand hygiene during wound care, and lack of a fully implemented water management plan.
Deficiencies (5)
F 0761: The facility failed to maintain medication refrigerator temperatures within the required 36°F to 41°F range, with observed temperatures as low as 28°F. Staff did not know the correct temperature range or actions to take when out of range.
F 0812: The facility stored opened and expired potentially hazardous foods, including ground beef and diced chicken, beyond recommended shelf lives and without proper labeling.
F 0837: The governing body did not implement a water management plan to address Legionella contamination. Multiple water samples tested positive for Legionella, and no resampling was done after August 2019.
F 0880: Staff failed to perform proper hand hygiene during wound care for two residents, not washing hands or changing gloves between dressing changes as required by policy.
F 0921: The facility did not maintain a safe, functional, sanitary, and comfortable environment due to inadequate water sampling and persistent Legionella contamination without appropriate remediation.
Report Facts
Legionella positive sample sites: 3
Legionella positive sample sites: 11
Ground beef shelf life: 21
Chicken shelf life: 14
Chicken opened package use time: 3
Medication refrigerator temperature: 28
Medication refrigerator temperature: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed failing to perform hand hygiene during wound care |
| LPN #1 | Licensed Practical Nurse | Observed not knowing correct medication refrigerator temperature range |
| LPN #2 | Licensed Practical Nurse | Observed not knowing correct medication refrigerator temperature range |
| Unit Manager | Stated plan to discard medications and replace refrigerator | |
| Nurse Educator | Stated no training provided on medication refrigerator temperature monitoring | |
| Director of Nursing | DON | Confirmed discarding medications due to temperature issues |
| Dining Director | DD | Interviewed regarding food storage practices |
| Chef Manager | CM | Interviewed regarding freezing and storage of ground beef |
| Utility Aide | UA | Responsible for receiving and storage of food items |
| Director of Facilities | DOF | Interviewed regarding Legionella water sampling and remediation |
| Infection Control Nurse | ICN | Interviewed regarding hand hygiene policy |
Inspection Report
Capacity: 60
Deficiencies: 0
Date: Inspection Report
Visit Reason
Summary of inspection history and citations for Woodland Pond at New Paltz
Findings
No citations or enforcement actions were recorded for this facility from October 1, 2021 through September 30, 2025.
Report Facts
Total inspections: 0
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