Highbridge Woodycrest Center

In the surveyor’s words

From the most serious findings on record at Highbridge Woodycrest Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Oct 6, 2022

  Based on observation, interviews, and record review conducted during the Recertification survey from 09/27/22 to 10/06/22, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during review of the Infection Control Task. Specifically, the facility did not have a qualified IP with specialized education, training, experience, or certification and in infection prevention and control. […]

• No harm, potential for more than minimal, patternF812May 20, 2026

  Based on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety. This deficiency was evident in one (1) of four (4) kitchen refrigerators and two (2) of four (4) unit pantry refrigerators observed during the survey. Specifically, the kitchen walk-in refrigerator contained expired deli meat products, and the Unit 3 and Unit 4 pantry refrigerators contained unlabeled, undated, expired, and decomposing food items. The findings include:The facility's Labeling and Dating System Protocol with a revised date of 10/12/2025 directed staff to follow manufacturers' expiration dates for all unopened products, including deli meats. […]

• No harm, potential for more than minimal, patternF880Jul 16, 2024

  483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control S483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. S483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: S483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility… […]

• No harm, potential for more than minimal, isolatedF882Jul 16, 2024

  Based on record review and interviews conducted during the Recertification Survey from 07/09/2024 through 07/16/2024, the facility did not ensure that the Infection Preventionist had completed specialized training in infection prevention and control. This was evident during the review of the Infection Control Task. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. […]

• No harm, potential for more than minimal, isolatedF657Oct 6, 2022

  Based on observation, record review and interview conducted during a Recertification and abbreviated survey (NY00294067), the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised after each assessment and as needed. This was evident for 1 (Resident #235) of 25 sampled residents. Specifically, various CCPs were not reviewed and revised upon Resident #235's quarterly assessment and improvement in functional status. The findings are: The facility policy titled Comprehensive Person-Centered Care Policy dated 10/27/2018, revised 7/29/2022 documented the CCP will be updated when there has been a significant change in the resident's condition and/or at a quarterly assessment. Resident #235 had diagnoses of psychosis and opioid abuse. […]