Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Osborn during CMS and state inspections, most recent first.
The facility did not document the time power was transferred to the generator during monthly tests for the transfer switch in 2024 and 2025, as required by NFPA standards. The Director of Facilities acknowledged the oversight and stated that the generator was serviced by a vendor during those months.
The facility did not ensure annual testing of all fire alarm system devices, specifically omitting the magnetic hold open devices, as observed during a life safety recertification survey. The last service by the vendor did not include these devices, and the service report was unavailable at the time of the survey.
The facility failed to provide service manuals for air mattress pumps, oxygen concentrators, and nebulizers during a survey, as required by the 2012 NFPA 99 Health Care Facilities Code. Additionally, there was no policy and procedure for testing patient care-related electrical equipment available. The Director of Facilities acknowledged the oversight and indicated that central supply was responsible for providing the manuals.
The facility was found deficient in providing sprinkler coverage under the first accessible landing in stairwell B and in the electrical switch gear room in the garage. The electrical room, which should only contain electrical equipment, had two ladders and two chairs, violating NFPA standards.
The facility did not maintain the emergency exit stairwell free of obstructions, as a radiator and an unsecured mat were found in stairwell C. The radiator was placed near the emergency exit door and connected to an extension cord, which was intended to prevent a sprinkler pipe from rupturing.
The facility was found non-compliant with plumbing fixture standards during a survey, as two out of three sinks in the kitchen's food prep areas had 3-inch blade handles instead of the required 4-inch wrist blade handles.
The facility did not review and update its emergency preparedness (EP) plan annually, as required. During a survey, it was found that the EP binders on two resident floors had not been reviewed since the year (YEAR). A nursing staff member mentioned the binder is used as a reference, and the DON stated that staff can access the information from the computer.
A facility failed to develop a comprehensive care plan for a resident's antibiotic use, as required. The resident, with mild cognitive impairment and on anticoagulant medication, was prescribed antibiotics upon admission. However, no care plan was documented to address this medication use. A nurse responsible for reviewing care plans had not reviewed the resident's chart since admission, resulting in the absence of a care plan to monitor for antibiotic side effects.
The facility's assessment was outdated and incomplete, failing to accurately determine resources needed for resident care. It used old acuity data and lacked details on staff assistance levels, educational requirements, and third-party staffing contracts. The Administrator admitted the staffing plan was based on goals, not actual needs, and the facility's unit definitions had changed due to increased short-term admissions.
The facility failed to adhere to food safety standards, with unlabeled and undated food items found in the kitchen and freezer, and a refrigerator in the dining room operating above the required temperature. The Executive Chef and Dining Operations Manager acknowledged these issues, which were not in compliance with the facility's policies.
The facility did not inform a resident's representative of the bed hold policy before and upon the resident's transfer to a hospital. The resident, who had severe cognitive impairment, was transferred due to respiratory issues. The facility's policy required written information about the bed hold to be provided, but this was not done. The Director of Social Services confirmed that social workers failed to provide the necessary notice.
A resident with severe cognitive impairment was transferred to the hospital without written notification to their representative or the Ombudsman. Facility staff, including social workers and nursing staff, failed to provide the required transfer/discharge notice, as confirmed by interviews with the Director of Social Services, the Director of Nursing, and the facility Administrator.
The facility did not complete the preadmission screening for two residents, as required by the PASARR process. The SCREEN DOH-695 forms for these residents were missing answers to specific items, which was acknowledged by the Director of Admissions and the Administrator. This oversight was identified during a recertification survey.
The facility failed to accurately post nurse staffing information, including the actual hours worked by CNAs and the facility's census. Discrepancies were noted on multiple dates where the documented staffing did not match the actual number of CNAs working. The Administrator confirmed that the postings did not account for schedule changes and lacked the required census information.
A resident with severe cognitive impairment was receiving supplemental oxygen without a proper physician's order specifying the flow rate or route of administration. The facility's policy required detailed orders for oxygen therapy, but the available order only instructed to maintain saturation above 92%. Observations showed the resident receiving oxygen at 4 liters per minute, which was not documented in the care plan or Treatment Administration Record, indicating a failure to adhere to professional standards.
The facility failed to notify the New York State Department of Health about the non-employment of certain subject employees within the required timeframe. Four employees with Negative Determination Letters were not removed from the Criminal History Record Check system within 30 days of their Final Denial letters. The facility's audit process only included active employees who were terminated, not prospective employees who were never hired, leading to this oversight.
Generator Testing Documentation Deficiency
Penalty
Summary
The facility failed to ensure that all required tests for the generator were conducted in accordance with NFPA 101, NFPA 110, and NFPA 99 standards. Specifically, during a life safety recertification survey, it was observed that the monthly generator logs for the years 2024 and 2025 were missing documentation of the time power was transferred to the generator during the monthly test for the transfer switch. This omission was noted for the months of May, (MONTH), and (MONTH) in 2024, and (MONTH) in 2025. The Director of Facilities acknowledged in an interview that the generator was serviced by a vendor during those months and committed to ensuring that the time of power transfer would be documented in the future.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will develop and implement a standardized log for generator load tests that includes transfer switch timeframes by 4/1/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 4/1/25 the Director of Facilities or designee will audit the Generator Log monthly through (MONTH) 31, 2025 and report findings to QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Fire Alarm System Testing Deficiency
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were tested annually in accordance with NFPA 101 standards. During a life safety recertification survey, it was observed that the inspection and testing report for the fire alarm system did not include the inspection and testing of the magnetic hold open devices. Additionally, the service report for these devices was not provided at the time of the survey. The last recorded service of the fire alarm system by the vendor was on September 24, 2024, but it did not cover the magnetic hold open devices. This oversight was confirmed during an interview with the Director of Facilities, who acknowledged the omission and stated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will contact the appropriate vendor to conduct testing of the magnetic hold open devices by 3/15/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 3/15/25 the Director of Facilities or designee will audit vendor reports monthly through (MONTH) 31, 2025 and report findings to QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Missing Service Manuals and Testing Procedures for PCREE
Penalty
Summary
The facility was found to be deficient in ensuring the availability of service manuals for patient care-related electrical equipment (PCREE) during a Life Safety Code survey. Specifically, the service manuals for air mattress pumps (Span, IPS Signa Relief, and Direct Supply), oxygen concentrators (Invacare Platinum XL), and nebulizers (McKesson) were missing and not provided at the time of the survey. These pieces of equipment were noted to be in use during the survey, indicating a lack of compliance with the 2012 NFPA 99 Health Care Facilities Code, which requires that such documentation be available. Additionally, the facility did not have a policy and procedure for testing the patient care-related electrical equipment readily available. During an interview, the Director of Facilities acknowledged that the service manuals were supposed to be provided by central supply and mentioned that a policy and procedure for the frequency of testing the equipment would be provided. This lack of documentation and procedural guidance represents a failure to adhere to the required standards for equipment maintenance and testing.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities will secure service manuals for noted patient care related electrical equipment by 3/18/25. - Clinical Educator or designee will review and update the Patient Care Related Electrical Equipment Policy by 4/15/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Beginning on 5/1/25, the Clinical Educator or designee will audit 5 patient care related electrical devices per month x12 months. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Clinical Educator
Deficient Sprinkler Coverage in Stairwell and Electrical Room
Penalty
Summary
The facility failed to ensure proper sprinkler coverage in accordance with NFPA 101 and NFPA 13 standards. During a life safety tour, it was observed that sprinkler coverage was missing under the first accessible landing in stairwell B. Additionally, the electrical switch gear room located in the enclosed garage lacked sprinkler coverage. The room, which is supposed to be dedicated to electrical equipment only, contained two ladders and two chairs, indicating the presence of combustible storage, which is not permitted under the specified conditions for not requiring sprinklers.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities immediately removed noted ladders and chairs from electrical switch gear room. - Director of Facilities or designee will conduct in-service education with Facilities Staff on the prohibition of combustible storage in the electrical equipment room by 3/20/25. - The Director of Facilities or designee will obtain quotes and will select an appropriate vendor to install an automatic sprinkler in the first accessible landing of Stairwell B by 3/31/25. - Once an appropriate vendor is identified, the Director of Facilities or designee will schedule sprinkler installation and permit process for Stairwell B, work expected to be completed by 4/21/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of facilities will conduct audit of electrical equipment room weekly x4 and then monthly x5. Updates will be provided during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Obstruction in Emergency Exit Stairwell
Penalty
Summary
The facility failed to maintain the emergency exit stairwell free of obstructions or impediments, as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that a radiator was placed in stairwell C near the emergency exit door, and it was connected to an extension cord. Additionally, an unsecured mat was found in the same stairwell. These obstructions were noted in one of the three stairwells on both resident floors. The Director of Facilities explained that the radiator was intended to prevent the sprinkler pipe at the bottom of the landing from rupturing, acknowledging the presence of these items in the stairwell.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities immediately removed radiator, unsecured mat and extension cord from Stairwell C. - Director of Facilities or designee will complete in-service education with Facilities Staff members on Preventing Obstruction of Means of Egress by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Beginning on 4/1/25 Director of Facilities or designee will complete audits to confirm unobstructed means of Egress for 3 out of 3 stairwells weekly x4 and then monthly x5. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Non-compliant Hand Washing Fixtures in Kitchen
Penalty
Summary
The facility failed to ensure that hand washing fixtures in the food preparation areas of the kitchen were compliant with regulatory requirements. During a recertification survey, it was observed that two out of three sinks in the food prep areas were equipped with 3-inch long blade handles instead of the required 4-inch wrist blade handles. This deficiency was noted during a tour of the kitchen, indicating non-compliance with the specified plumbing fixture standards for areas used by food handlers.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will purchase and install 4 inch wrist blade handles for the 2 out of 3 identified sinks located in food prep areas by 4/20/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Facilities or designee will provide updates during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Failure to Annually Review Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its emergency preparedness (EP) plan was reviewed and updated at least annually, as required by Emergency Preparedness 483. During a Life Safety recertification survey, it was observed that the emergency preparedness binders on both the first and second floors had not been reviewed since the year (YEAR). This deficiency was confirmed through documentation review and staff interviews. A nursing staff member indicated that the EP binder is used as a reference, while the Director of Nursing stated that staff could access the information from the computer.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities discarded outdated hard copies of Emergency Preparedness Plan noted on 2 out of 2 resident floors and replaced them with updated hard copies of the Emergency Preparedness Plan last revised in (MONTH) of 2024. - Director of Nursing will complete in-service education with Licensed Staff on accessibility of Emergency Preparedness Plan by 4/15/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Beginning on 3/31/25 Director of Facilities will conduct monthly reviews of the Emergency Preparedness Binders on Pavilion 1 and 2 as well as electronic versions to ensure continued regulatory compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Failure to Develop Comprehensive Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to ensure that a person-centered comprehensive care plan was developed for a resident regarding antibiotic medication use. This deficiency was identified during a recertification survey. The resident in question had a diagnosis that required antibiotic medication, as documented in their Admission Minimum Data Set 3.0 assessment, which also noted mild cognitive impairment and the use of anticoagulant medication. Despite the physician's orders for antibiotics, there was no documented evidence of a comprehensive care plan addressing the antibiotic use. A registered nurse, responsible for reviewing care plans, admitted to not having reviewed the resident's chart since admission and acknowledged the absence of a care plan to monitor for side effects related to the antibiotics.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Director of Nursing or designee updated the person centered comprehensive care plan of resident #30 to address antibiotic medication use. Identification of other residents having the potential to be affected was accomplished by: - Residents admitted whom require the development of person-centered comprehensive care plans with objectives and timeframe's to meet the resident's needs have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Nursing or designee will in-service registered nurses on the Comprehensive Care Planning Policy by 3/31/25. - Clinical Care Manager or designee will ensure person-centered comprehensive care plans are developed with objectives and timeframe's to meet the resident's needs by 4/1/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Nursing or designee will audit 10% of resident Comprehensive Care Plans. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing
Inadequate Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was updated to accurately determine the resources necessary for competent resident care during daily operations. The assessment, which was supposed to guide staffing and resource allocation, was found to be outdated and incomplete. Specifically, it used acuity data from April 2023 to June 2023 to determine staffing needs, which did not reflect the current resident population or their care requirements. Additionally, the assessment did not specify the level of staff assistance required for residents' activities of daily living, nor did it include the educational requirements for all personnel or the contracts with third-party staffing agencies used to meet staffing needs. During an interview, the Administrator acknowledged responsibility for creating the Facility Assessment and determining the necessary staffing and equipment. However, the Administrator admitted that the staffing plan was based on the facility's goals rather than the actual number of staff required for day-to-day resident care. The facility had redefined its units, with the second floor no longer exclusively serving long-term residents due to an increase in short-term admissions. Despite working with a third-party staffing agency and using a computer application for scheduling, the facility's assessment and staffing plan did not adequately address the current operational needs.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - The Administrator reviewed and confirmed that acuity data captured in Quarter 2 of 2024 is included in the Facility Wide Assessment. - The Administrator reviewed and confirmed the Facility Wide Assessment includes education required by all personnel. Identification of other residents having the potential to be affected was accomplished by: - Residents residing within the nursing facility have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - The Administrator or designee will update the Facility Wide Assessment to include third-party staffing agency contracts by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Administrator or designee will audit the Facility Assessment. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Administrator
Food Storage and Temperature Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a recertification survey, surveyors observed multiple instances of non-compliance with the facility's own policies regarding food storage and labeling. In the kitchen's produce refrigerator, several food items, including salmon, herbs, and various produce, were found unlabeled and undated. Similarly, in the freezer, bags of pasta and hash browns were also observed without labels or dates. The Executive Chef acknowledged awareness of the food items and their arrival dates, as they were responsible for ordering, but this did not align with the facility's policy requiring visible dating of potentially hazardous foods. Additionally, the surveyors noted that the small refrigerator in the second-floor dining room was not maintaining the proper temperature for food safety. The refrigerator, which contained food and snacks for residents, was recorded at 46 degrees Fahrenheit, exceeding the facility's policy requirement of 45 degrees Fahrenheit or below. The Dining Operations Manager confirmed that refrigerator temperatures were checked daily and acknowledged the elevated temperature during the survey. These observations indicate a failure to adhere to established food safety protocols, potentially compromising the safety and quality of food provided to residents.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Executive Chef or designee discarded unmarked and undated food items. - Executive Chef or designee labeled produce bins impacted by improper storage techniques. - Executive Chef marked canned goods and other dry goods with "received on" adhesive labels. - Operations Manager or designee placed service call to address the impacted refrigerator. Identification of other residents having the potential to be affected was accomplished by: - Residents who consume meals prepared in the facility’s kitchen have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Dining Services or designee will in-service Dining Services Staff on Food Labeling Policy by 3/31/25. - Director of Dining Services or designee will in-service Dining Services Staff on Refrigeration Storage Policy by 3/31/25. - Director of Dining Services or designee will in-service Shift Supervisors on Care & Operation of Refrigerators and Freezers Policy by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Dining Services or designee will audit labeling and dating of stored products weekly x10 beginning on 4/1/25. - Director of Dining Services or designee will audit refrigerator temperature logs weekly x10 beginning on 4/1/25. - Audit findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Dining Services
Failure to Inform Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of the bed hold policy before and upon the resident's transfer to a hospital. This deficiency involved a resident with severe cognitive impairment who was transferred to the hospital due to shortness of breath and wheezing. The facility's policy required that both the resident and their representative receive written information about the bed hold policy and payment details at admission and before any hospital transfer. However, upon review of the resident's medical record, it was found that neither the resident nor their representative received the necessary written information regarding the bed hold policy. During an interview, the Director of Social Services acknowledged that the social workers, who were responsible for providing this notice, did not complete the task.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: ò No immediate action could be taken for residents found to be affected. Identification of other residents having the potential to be affected was accomplished by: ò Residents who are placed on leave or transferred out of the facility, planned or unplanned, have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: ò Director of Social Services or designee will identify and implement a compliant Bed Hold Form by 3/20/25. ò Administrator or designee will in-service Social Services Staff on the issuance of Bed Hold Notices before or upon transfer by 3/31/25. ò Director of Nursing or designee will in-service Licensed Nursing Staff on the issuance of Bed Hold Notices before or upon transfer by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: ò Director of Social Services or designee will audit 100% of resident transfers and overnight leaves of absence for written notification of the facility bed hold policy to resident or resident representative. Beginning on 4/1/25 audits will be weekly x4 weeks and then Monthly x 3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Social Services
Failure to Notify Resident and Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident and their representative were notified in writing of the reason for a transfer to the hospital. Specifically, a resident with severe cognitive impairment was transferred to the hospital due to shortness of breath and wheezing, but there was no documented evidence that the resident's family or representative received written notification of the transfer. Additionally, the facility did not provide the required notification to the State Long-Term Care Ombudsman's Office. Interviews with facility staff, including the Director of Social Services and the Director of Nursing, revealed that the responsibility for providing the transfer/discharge notice fell on the social workers and nursing staff. However, they failed to complete this task for the resident in question. The facility Administrator acknowledged that the resident's family should have received written information regarding the transfer and discharge process, but this did not occur. The Ombudsman office confirmed that they did not receive any documentation regarding the resident's discharge.
Plan Of Correction
Plan of Correction: Approved March 13, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: ò No immediate action could be taken for residents found to be affected. Identification of other residents having the potential to be affected was accomplished by: ò Residents who are transferred and/or discharged from the facility, planned or unplanned have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: ò Director of Social Services or designee will identify and implement a compliant Transfer and Discharge Form by 3/20/25. ò Director of Social Services or designee will establish a transfer and discharge communication protocol with the local ombudsman by 3/31/25. ò Administrator or designee will in-service Social Services Staff on Transfer and Discharge Protocol by 3/31/25. ò Director of Nursing or designee will in-service Licensed Nursing Staff on Transfer and Discharge Protocol by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: ò Director of Social Services or designee will audit 100% of resident discharges and/or transfers for written notification of reason for transfer and/or discharge to resident or resident representative and the ombudsman. Beginning on 4/1/25 audits will be weekly x4 weeks and then Monthly x 3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Social Services
Incomplete Preadmission Screening for Two Residents
Penalty
Summary
The facility failed to ensure a complete preadmission screening was conducted for two residents during the recertification survey. Specifically, the SCREEN DOH-695 form was incomplete for these residents. Resident #169, who was admitted from an acute care hospital with unspecified diagnoses, had an incomplete form dated 7/25/2024, with item #21 left unanswered. Similarly, Resident #35, also admitted from an acute care hospital with unspecified diagnoses, had a form dated 01/10/2025, where items 24, 25, and 26 in the Level I Review for Possible Mental Condition/Developmental Disability (MR/DD) section were not completed. During interviews, the Director of Admissions acknowledged that the screens for all residents should be reviewed and completed prior to admission. However, upon reviewing the forms for the two residents, it was confirmed that the necessary items were not answered. The Administrator stated that the Admissions Department was responsible for reviewing the PASARR SCREEN forms before resident admission and was unaware of the incomplete forms. This oversight was identified as a deficiency under 10 NYCRR 415.11(e).
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Director of Admissions requested and received completed SCREEN Form DOH - 695 from the hospital of origin for Resident #169 and Resident #35. Identification of other residents having the potential to be affected was accomplished by: - Residents admitted to the nursing facility have the potential to be impacted. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Administrator or designee will in-service Admissions Staff on PASARR Policy and ensuring that complete preadmission screening is conducted by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Admissions or designee will audit 50% of new admissions’ PASARR Forms. Beginning on 4/1/25 audits will be conducted weekly x4 weeks and then monthly x3 months. Findings will be reported during QAPI. Date of Completion and Person Responsible: - 4/20/25, Director of Admissions
Inaccurate Nurse Staffing Records and Missing Census Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information included the current census and the actual hours worked by nursing staff, specifically Certified Nursing Assistants (CNAs). On multiple occasions, the Daily Nurse Staffing records did not accurately reflect the number of CNAs working on specific shifts. For instance, on February 15, 2025, the staffing records indicated that 7 CNAs worked the 7:00 AM to 3:30 PM shift, while assignment sheets showed 8 CNAs were present. Similarly, discrepancies were noted on February 16 and February 18, 2025, where the documented staffing did not match the actual number of CNAs working or the hours worked. Additionally, the facility failed to document the census on these dates, which is a required component of the daily staffing posting. The Administrator acknowledged that the Staffing Coordinator was responsible for posting the Daily Nurse Staffing at the beginning of each day. However, the Administrator admitted that the postings did not account for unforeseen changes to the schedule and did not reflect the actual hours worked by the nursing staff. Furthermore, the postings did not include the facility's daily census, which is a requirement. This lack of accurate and complete staffing information was observed during the recertification survey conducted from February 12 to February 19, 2025, and was a violation of the regulatory requirements.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: ò No residents identified as having been affected. Identification of other residents having the potential to be affected was accomplished by: ò Residents residing within the nursing facility have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: ò Director of Nursing or Designee will develop a procedure to ensure accuracy of Posted Nursing Staffing Information by 3/20/25. ò Director of Nursing or designee will in-service Staffing Coordinator on Posted Nursing Staffing Information to ensure current census and total actual hours worked by nursing staff are included by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: ò Administrator or designee will audit 20% of Posted Nursing Staffing Information. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing
Deficiency in Respiratory Care Documentation and Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required supplemental oxygen. The resident, who was severely cognitively impaired, was receiving oxygen therapy without a proper physician's order specifying the liter flow rate or route of administration. The facility's policy required a detailed order for oxygen therapy, including the type of administration system, flow rate, and monitoring parameters. However, the only order available was to titrate oxygen to maintain saturation above 92%, without specifying the necessary details. Observations revealed that the resident was receiving oxygen at 4 liters per minute via nasal cannula, which was not documented in the resident's comprehensive care plan or the Treatment Administration Record. Interviews with nursing staff confirmed the lack of a specific order for the oxygen therapy being administered. The deficiency was identified during a recertification survey, highlighting the facility's failure to adhere to its own policy and ensure proper documentation and physician orders for oxygen therapy.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate action(s) taken for the resident(s) found to have been affected include: - Medical Director facilitated in-service education with the provider responsible for entering Resident #281’s supplemental oxygen order. - Director of Nursing or designee reviewed and updated the physician order [REDACTED]. - Director of Nursing or designee conducted an audit of physician orders [REDACTED]. Audit Findings were: Active supplemental oxygen orders contained indication for use, flow rate, and route of administration. Identification of other residents having the potential to be affected was accomplished by: - Residents receiving supplemental oxygen have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Nursing or designee will in-service Licensed Staff and Medical Staff on adhering to Oxygen Therapy Policy by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Nursing or designee will audit 100% of residents receiving supplementary oxygen. Beginning on 4/1/25 audits will be conducted weekly x4 weeks and then Monthly x3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing
Failure to Timely Update Criminal History Record Check System
Penalty
Summary
The facility failed to notify the New York State Department of Health when certain subject employees were no longer employed, as required by the Criminal History Record Check system. This deficiency was identified during a recertification survey, where it was found that four employees with Negative Determination Letters were not removed from the system within the mandated 30-day period following their Final Denial letters. Specifically, Employees #7, #8, #9, and #10 were not removed in a timely manner, with their Form 105 submissions occurring well beyond the 30-day requirement. The facility's policy on fingerprinting, dated 9/19/2019, mandates timely submission of terminations to keep records current. However, the Human Resources/Authorized Person revealed that these employees were never actually hired or started working at the facility before receiving their Final Denial letters. The facility's audit process, which is conducted quarterly, only included active employees who were terminated and did not account for prospective employees who were never hired. This oversight led to the delay in updating the Criminal History Record Check system, resulting in the cited deficiency.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Vice President of Human Resources or designee sent notification of termination to the New York State Department of Health for Employee #7, #8, #9 and #10. - Vice President of Human Resources or designee reviewed entire Criminal History and Record Check roster to ensure all termination notifications were sent to the New York State Department of Health for applicable staff. Identification of other residents having the potential to be affected was accomplished by: - No potential for resident impact identified. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Vice President of Human Resources or designee will complete in-service education with Human Resources Staff on provider notification requirements by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Vice President of Human Resources or designee will audit 100% of the Criminal History and Background Check roster for compliance. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: - 4/20/25, Vice President of Human Resources
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rye
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Enclave At Rye Rehab And Nursing Ctr | 2.2 mi | ★★★★★ | 2 | 0 |
| Sarah Neuman Center For Rehabilitation And Nursing | 2.7 mi | ★★★★★ | 2 | 0 |
| King Street Home Inc | 4.4 mi | ★★★★★ | 3 | 0 |
| White Plains Center For Nursing Care, L L C | 5.2 mi | ★★★★★ | 29 | 0 |
| Martine Center For Rehabilitation And Nursing | 5.6 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.