Woodbury Heights Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Woodbury Heights Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 29, 2024

  Based on observation, record review and interviews conducted during an abbreviated survey (NY00322869) initiated on [DATE] the facility failed to ensure that each resident receive treatment and care in accordance with professional standards of practice for 1 out of 5 residents (Resident #1). Specifically, on [DATE] at 6:05 PM Resident #1 experienced respiratory distress. At 7:55 PM Nurse Practitioner #1 assessed the resident and ordered the resident to be transferred to the hospital. Registered Nurse #1 did not follow the order to call for emergency medical transportation, instead Registered Nurse #1 called a non-emergency ambulance service. The company reported that it would take 2 hours for the ambulance to arrive. […]

• Immediate jeopardy, isolatedF689Mar 4, 2024

  Based on observation, record review and interview during an abbreviated survey (NY00334107), the facility failed to have a system in place to ensure that each resident received adequate supervision to prevent accidents. Specifically, Resident #1 had a history of unsafe smoking and was found by facility staff smoking unsupervised outside of the designated time on four occasions. The facility staff were aware of the resident's noncompliance with smoking; however, there were no interventions put in place to maintain the resident's safety. Resident #1 utilized supplemental oxygen therapy for the diagnosis of Chronic Obstructive Pulmonary Disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). […]

• Immediate jeopardy, isolatedF678May 9, 2022

  Based on observation, staff interviews and record review during an abbreviated survey (NY 474), the facility failed to accurately identify the resident's advance directive status and did not initiate Cardiopulmonary Resuscitation (CPR) when a resident was found unresponsive and with no pulse. This was evident for 1 (Resident #1) of 4 residents reviewed for Advance Directives. Specifically, Resident #1 who had a Full Code status as documented in the Social Work notes, Physician notes and the Comprehensive Care Plan was not provided with life- saving CPR when found unresponsive and with no pulse. Licensed Practical Nurse (LPN) #1 and Registered Nurse Supervisor (RNS) #1 did not verify the resident's code status after noting a discrepancy and did not initiate CPR. […]

• Actual harm, isolatedF686Aug 10, 2023

  Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00310476) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #738) of four residents reviewed for Pressure Ulcers. Specifically, Resident #738 was admitted to the facility with an unstageable pressure ulcer to the sacral region which deteriorated to a Stage 4 pressure ulcer. The resident was identified as a high risk for pressure ulcer development. […]

• Actual harm, isolatedF697Aug 10, 2023

  Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that pain management was provided to each resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #116) of two residents reviewed for Pain Management. Specifically, Resident #116 with diagnosis of Multiple Sclerosis (MS-a chronic disease of the central nervous system) had a Physician's order to receive Baclofen (a muscle relaxant) 10 milligrams (mg), give two tablets 20 mg every 12 hours at 6:00 AM and 6:00 PM for muscle spasms. […]