Inspection Reports for
Osborn Home Care
101 Theall Road, Rye, NY 10580, Rye, NY, 10580
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Feb 19, 2025
Visit Reason
The inspection was a recertification survey conducted from 02/12/2025 to 02/19/2025 to assess compliance with regulatory requirements for the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of resident transfers and bed hold policies, incomplete PASARR screening forms, lack of comprehensive care plans for antibiotic use, inadequate respiratory care documentation, inaccurate nurse staffing postings, improper food storage and labeling, and an outdated facility-wide staffing assessment.
Deficiencies (8)
F 0623: The facility failed to provide timely written notification to Resident #7 and their representative regarding transfer to the hospital and notification to the Ombudsman Office.
F 0625: The facility did not inform Resident #7 or their representative in writing about the bed hold policy before hospital transfer.
F 0645: The facility did not complete required PASARR screening forms for Residents #169 and #35, missing answers to key items.
F 0656: The facility failed to develop and implement a comprehensive care plan addressing antibiotic use for Resident #30.
F 0695: Resident #218 received supplemental oxygen without a complete physician order specifying flow rate and route of administration.
F 0732: The facility did not post nurse staffing information daily with accurate census and actual hours worked by Certified Nursing Assistants.
F 0812: The facility stored food in unlabeled and undated containers and maintained food at improper temperatures in a resident dining refrigerator.
F 0838: The facility-wide assessment was not updated to include required education for personnel, third-party staffing agency contracts, and used outdated acuity data for staffing needs.
Report Facts
Residents reviewed for PASARR: 16
Residents with incomplete PASARR screening: 2
Certified Nursing Assistants: 7
Certified Nursing Assistants: 8
Certified Nursing Assistants: 5
Certified Nursing Assistants: 7
Certified Nursing Assistants: 9
Certified Nursing Assistants: 10
Facility beds on Short Term Rehab Unit: 42
Facility beds on Long Term Unit: 42
Admissions on Short Term Rehab Unit: 157
Admissions on Long Term Unit: 13
Food refrigerator temperature: 46
Oxygen flow rate observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Charge Nurse | Interviewed regarding care plan development for Resident #30 |
| Licensed Practical Nurse #1 | Observed oxygen concentrator and documented oxygen use for Resident #218 | |
| Registered Nurse Manager #2 | Interviewed about oxygen therapy orders and documentation for Resident #218 | |
| Director of Social Services | Interviewed about responsibility for transfer/discharge and bed hold notices | |
| Director of Nursing | Interviewed about notification of resident transfer to hospital | |
| Administrator | Interviewed about notification processes and staffing postings | |
| Director of Admissions | Interviewed about PASARR screening form completeness | |
| Executive Chef | Interviewed about unlabeled and undated food items in kitchen | |
| Dining Operations Manager | Interviewed about refrigerator temperature in dining area |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 26, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations related to resident care, specifically focusing on notification of changes in condition and pressure ulcer prevention and treatment for Resident #1.
Findings
The facility failed to immediately notify the resident's representative of a change in condition related to an unstageable pressure ulcer. Additionally, the facility did not ensure timely reassessment or adequate pressure relief interventions, resulting in the worsening of the resident's pressure ulcer from stage 2 to stage 4.
Deficiencies (2)
F 0580: The facility did not ensure that the resident and designated representative were immediately informed of a change in condition for Resident #1 involving an unstageable pressure ulcer discovered on 11/16/2022. Notification to the representative occurred only on 11/23/2022.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevention for Resident #1, who had a stage 2 pressure ulcer on admission that was not reassessed timely and worsened to a stage 4 ulcer. Pressure relief interventions were not adequately applied or documented.
Report Facts
Residents Affected: 1
Pressure ulcer size: 6
Pressure ulcer size: 3
BIMS score: 15
Pain level: 10
Pressure ulcer treatment initiation date: Nov 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #1 | Director of Nursing | Assessed Resident #1's sacral wound and confirmed notification failures |
| RN #4 | Registered Nurse | First assessed sacral wound and applied dressing; interviewed regarding wound care |
| Administrator | Provided statements on notification policies and wound tracking | |
| DSW | Director of Social Work | Discussed care plan meeting and family notification |
| RN #1 | Registered Nurse | Described admission skin assessment process |
| CNA #1 | Certified Nursing Assistant | Provided care and reported skin changes |
| RD | Registered Dietician | Assessed nutrition and intake related to wound healing |
| DON #2 | Director of Nursing | Current DON who proposed hiring wound specialist and nurse |
| RN #2 | Registered Nurse | Provided statements on wound care protocol |
| AP | Attending Physician | Provided orders and statements on wound management |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 17, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 2/13/2023 to 2/17/2023 to assess compliance with federal regulations for nursing home certification.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of resident transfers and bed hold policies, incomplete baseline and comprehensive care plans, improper respiratory care, delayed pain medication administration, and inadequate pest control measures with evidence of mice in resident areas.
Deficiencies (7)
F 0623: The facility did not provide timely written notification to residents or their representatives and the Ombudsman before transfer or discharge to the hospital for 3 residents.
F 0625: The facility failed to notify residents or their representatives in writing about the facility Bed Hold Policy before transfer to the hospital for 3 residents.
F 0655: The facility did not develop baseline care plans within 48 hours of admission for 2 residents reviewed.
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for multiple residents, including lack of care plans for pressure ulcers, antipsychotic medications, nutrition, and other medical conditions.
F 0695: The facility did not provide safe and appropriate respiratory care; one resident received 3 liters of oxygen instead of the ordered 2 liters.
F 0697: The facility failed to provide timely pain management; one resident's pain medication was administered late and without assessing pain level before administration.
F 0925: The facility did not maintain a pest control program to prevent mice; mice and droppings were observed in resident rooms and entry points were not properly sealed.
Report Facts
Residents reviewed for transfer notification: 3
Residents reviewed for baseline care plan: 2
Residents reviewed for care plan completeness: 5
Oxygen liters ordered vs administered: 2
Pain medication administration delay: 75
Mouse sightings reported: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Stated facility does not provide transfer notices or Bed Hold Policy notices | |
| Administrator | Acknowledged responsibility for transfer notices and Bed Hold Policy notices, and care plan issues | |
| Registered Nurse (RN #2) | Unaware of transfer notice forms | |
| Certified Nurse Assistant (CNA #1) | Reported resident not wearing heel boots due to laundry | |
| Registered Dietician | Responsible for nutrition care plans; acknowledged missing nutrition care plan for Resident #43 | |
| Licensed Practical Nurse (LPN #4) | Set oxygen flow meter; unaware why oxygen was set at 3 liters | |
| Director of Nursing (DON) | Acknowledged late pain medication and care plan deficiencies | |
| Nurse Practitioner (NP) | Explained expectations for oxygen orders and nursing responsibilities | |
| Licensed Practical Nurse (LPN #1) | Administered pain medication late without assessing pain scale | |
| Certified Nursing Assistant (CNA #2) | Reported resident pain and delay in nurse response | |
| Director of Facilities | Acknowledged mice presence and ongoing extermination efforts |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 14, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in timely administration of medications, posting of nurse staffing information, food safety practices including use of hair restraints, and infection prevention practices related to hand hygiene and glove use during wound care.
Deficiencies (4)
F 0684: The facility did not ensure timely administration of Cardizem CD medication for Resident #63, with multiple instances of medication given beyond the acceptable one-hour window before or after the prescribed time.
F 0732: The facility did not post daily nursing staff information consistently, with missing postings from 10/22 to 11/7/19 and for 11/10 and 11/11/19, making the information unavailable to residents and visitors.
F 0812: Dietary staff and assisting nursing staff were observed not wearing required hair restraints during food preparation and serving, violating professional food safety standards.
F 0880: Facility staff did not follow proper hand hygiene and glove technique during wound care for Resident #226, resulting in potential cross-contamination and infection risk.
Report Facts
Medication administration delays: 6
Staffing posting gaps: 17
Residents affected: 7
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in infection control deficiency for improper hand hygiene and glove use during wound care |
| LPN #2 | Licensed Practical Nurse | Named in medication administration deficiency for administering medication late due to resident refusal |
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for late documentation of medication administration |
| LPN #4 | Licensed Practical Nurse | Named in medication administration deficiency for administering medication late due to resident physical therapy |
| Food Service Director | Food Service Director | Interviewed regarding food safety deficiencies and confirmed staff training on hair restraint use |
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