The Osborn

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 2/12/25 to 2/19/25, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital for one of one residents reviewed for hospitalization (Resident #7). Specifically, Resident #7 was transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the resident or the resident's representative, and that notification was sent to the Ombudsman Office.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey conducted from 2/12/25 to 2/19/2,the facility did not ensure that a resident's representative was informed of the facility's bed hold policy before and upon transfer to a hospital for one of one residents reviewed for hospitalization (Resident #7). Specifically, Resident #7 was transferred to the hospital on 8/22/24, and the facility did not provide the resident or their representative written information regarding the bed hold.

Inspectors wroteBased on record review and interviews during the Recertification survey from 02/12/2025 to 02/19/2025, the facility did not ensure that a complete preadmission screening was conducted. This was evident for 2 (Resident #169 and Resident # 35) residents reviewed for Preadmission Screening and Resident Review (PASARR) of 16 residents. Specifically, the SCREEN DOH - 695 form was incomplete. There was no documentation of answers to items 21, 24, 25, and 26.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure person-centered comprehensive care plans were developed with objectives and timeframe's to meet the resident's needs. This was evident for 1 (Resident #30) of 5 residents reviewed for unnecessary medications. Specifically, Resident #30 did not have a care plan developed to address antibiotic medication use.

Inspectors wroteBased on observation, interview and record review during the Recertification survey from 2/12/25 to 2/19/25, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #281) reviewed for respiratory care. Specifically, Resident #281 was receiving supplemental oxygen without a physician's order, indication for use, flow rate and route of administration.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure the posted nurse staffing included the census and total actual hours worked by nursing staff. This was evident during review of Staffing. Specifically, the posted nurse daily staffing did not contain the facility's current census and actual hours worked by Certified Nursing Assistants on each shift.

Inspectors wroteBased upon record review, observations,and interviews conducted during a recertification survey from 02/12/2025 to 02/19/2025, the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, unmarked undated containers of food were observed in the refrigerator and freezer, and food was not maintained at the proper temperature in the second-floor dining facility's small refrigerator.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to care for residents competently during day-to-day operations. This was evident during review of Staffing. Specifically, the Facility Assessment did not include the education required by all personnel, a third-party staffing agency contract required to meet staffing needs, and used acuity data from 4/2023 through 6/2023 to determine their resident population staffing needs.

Inspectors wroteBased on observations, interviews, and record review during the recertification and abbreviated surveys (NY00309912), it was determined for two of two resident occupied floors, the facility did not maintain a safe and comfortable environment by not ensuring the exclusion of mice in the facility. Specifically, during an on-site investigation conducted on 2/13/23 through 2/14/23, between the hours of 9:00 AM to 4:00 PM, observation was made of a mouse and mouse droppings in a resident room.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey (2/13/23 to 2/17/23), it was determined that the facility did not implement care plan interventions and the facility did not develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, and nursing needs that were identified in the comprehensive assessment. [...]

Inspectors wroteBased on record review and interview during the recertification survey conducted from [DATE]-[DATE], the facility did not ensure a baseline care plan (BCP) was developed within 48 hours of admission for 1 of 1 resident reviewed for death (#429) and 1 of 1 reviewed for respiratory care (#432). Specifically, a BCP was not completed for Residents # 429 and # 432 within 48 hours of admission to the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey 2/13/2023- 2/17/2023, the facility did not ensure that a resident who required respiratory care, was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one of one resident (#432) reviewed for Respiratory Care. Specifically, Resident #432 was observed receiving three liters of oxygen via nasal cannula, although the physician order documented the resident was to receive 2 liters of oxygen. The finding is: Resident #432 was admitted on [DATE] with diagnoses including metastatic breast cancer, Syncope, and collapse. [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey 2/13/2023 - 2/17/2023, the facility did not ensure that pain management was provided to 1 of 1 resident (Resident #74) reviewed for pain mamagement who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences Specifically, nursing staff did not administer pain medications as per physician order to Resident #74 who complained of pain. The finding is: The 10/19/2017 facility Policy and Procedure titled 'Pain Management Program documented that residents have the right to have their pain thoroughly assessed and promptly treated, residents will be assessed for pain using the appropriate pain scale on admission and new onset of pain either verbal or observed and after an intervention of pain relief. [...]

Inspectors wroteBased on record review and interview conducted during the Recertification Survey 2/13/23-2/17/23, it was determined for 3 of 3 residents (#5, #27 and #179) reviewed for hospitalizations, the facility did not ensure the resident or the resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood and the facility did not notify the Ombudsman. Specifically, Resident #5, #27 and Resident #179 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident's representatives or that notification was sent to the Ombudsman. This was evidenced by the following: [...]

Inspectors wroteBased on record review and interview conducted during the Recertification Survey 2/13/23-2/17/23, it was determined that for 3 of 3 residents (#5, #27 and #179) reviewed for hospitalizations, the facility did not ensure that the residents or the resident's representatives were notified in writing of the facility Bed Hold Policy. Specifically, Resident #5, #27 and Resident #179 were transferred to the hospital and the facility could not provide evidence that a written notice of the facility Bed Hold Policy was provided to the residents or the resident's representatives. This was evidenced by the following: A review of the facility policy, ''Bed Hold last reviewed 9/18/2019 documented that the facility will provide written information about bed hold and payment amount before transfer to the hospital. 1. [...]

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure that food was prepared and served in accordance with professional standards of food safety practice. The FDA guidelines, a model code used by most jurisdictions to develop State and Local regulations, Chapter 1 Subpart 14 State Sanitary Code documented that dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food according to citing Subpart 14-1.72 (c) all persons with a food service establishment who work in areas where food is prepared are to use hats, caps, or hair nets as restraints which minimize hair contact with hands, food and food contact surfaces.

Inspectors wroteBased on interviews and record review conducted during a recertification survey, the facility did not consistently ensure that for 1 of 7 residents reviewed for unnecessary medications that the professional standard of practice was met for the timely administration of medications. Specifically, Resident # 63 did not receive her blood pressure medication in a timely fashion. Resident #63 is a [AGE] year-old woman who was admitted to the facility on [DATE] for rehabilitation services with diagnoses including atrial fibrillation, hypertension and hip fracture. The resident's doctors' orders for the treatment of her atrial fibrillation and hypertension beginning on 10/15/19 was Cardizem CD 180mg two times a day. The medical record of Resident #63 was reviewed for the month of November 2019 on 11/14/19. The resident was scheduled to receive her Cardizem CD medication at 9AM and 9PM daily. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that facility staff followed proper hand hygiene, and gloving technique to prevent cross contamination, and the spread of infection. Specifically, removal of soiled gloves and hand hygiene were not observed during a wound care procedure for 1of 3 residents (Resident # 226) reviewed for pressure ulcer.

Inspectors wroteBased on interview and observation during the most recent recertification survey the facility did not ensure daily nursing staff information was posted. It also was not available to residents or visitors.