Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Woodbury Heights Nursing and Rehabilitation Center
Woodbury, NY · 606 certified beds · Last Life Safety survey October 23, 2024
CMS Certification Number 335555 · first certified December 1977
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed June 1, 2016 (change of ownership)to COLD SPRING HILLS CENTER FOR NURSING AND REHABILITATION from UPR CARE CORP
Position within NY
36 citations — more than 95% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 12 citations; the earlier surveys in the window averaged 12. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: April 2026 to December 2026. This facility’s last Life Safety survey was October 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 36 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 36 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 24, 2021 | 4 |
| August 10, 2023 | 20 |
| October 23, 2024 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0161 | Use approved construction type or materials. | 3 | 2024-10-23 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2024-10-23 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-10-23 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-10-23 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-10-23 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2023-08-10 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2024-10-23 |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | 1 | 2023-08-10 |
What the citations cover
- Smoke Deficiencies 14
- Egress Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Construction Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 14 |
| Egress Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Construction Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 23, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (November 11, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (November 22, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 21, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 22, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 22, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 23, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (January 23, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (December 26, 2024) |
| K-0907 | Ensure medical gas and vacuum systems have documented maintenance programs. | Deficient, Provider has date of correction (January 23, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 22, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (January 23, 2025) |
August 10, 2023 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 30, 2023) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0161 | Use approved construction type or materials. | Waiver has been granted (January 26, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 11, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 10, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 30, 2023) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (January 26, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 27, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 30, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Deficient, Provider has date of correction (October 10, 2023) |
| K-0915 | Have proper power supply for life support equipment. | Deficient, Provider has date of correction (December 28, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (January 26, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 30, 2023) |
May 24, 2021 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Waiver has been granted |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 23, 2021) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (July 23, 2021) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (July 23, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.