Oswego Operator, LLC

Inspectors wroteThe facility reported a census of 29 residents and one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food borne illness to the residents of the facility. - Initial tour of the kitchen on 12/28/25 at 10:40 AM, revealed the following areas of concerns:There was an area on the floor at the entry to the kitchen from the dining area, approximately six inches long and one inch wide, that was missing tiles. There were multiple areas of the ceiling, including one area above the hand washing sink, that had flaking paint. There were three flies in the kitchen and an open tub of butter sitting on the counter next to an open bag of biscuits. There were various food waste items on the floor. [...]

Inspectors wroteThe facility reported a census of 29 residents. Based on observation, interview and record review the facility failed to provide a safe and functional handrails in three of four hallways.

Inspectors wroteThe facility reported a census of 29 residents. The sample included 12 residents with four residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 4, R9, and R32 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. The facility also failed to provide R4 or the responsible party with a bed hold.

Inspectors wroteThe facility reported a census of 29 residents; there were 12 residents sampled, which included two residents selected for closed record review. Based on observation, interview, and record review the facility failed to ensure nursing documentation in Resident (R) 10's health record met the professional standards of care when staff repeatedly documented application and removal of compression stockings even when they were not applied, inaccurately representing the provision of treatments.

Inspectors wroteThe facility reported a census of 29 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel for weekends.

Inspectors wroteThe facility reported a census of 29 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to licensed nursing coverage 24 hours/day.

Inspectors wroteThe facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure staff distributed ice to residents in a sanitary manner, failed to sanitize glucometers with appropriate sanitizing agent and failed to ensure staff administered medications in a sanitary manner to prevent the spread of infections amongst the residents.

Inspectors wroteThe facility identified a census of 29 residents, with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on interview, record review, and observation, the facility failed to follow physician's orders for one of the five sampled residents, Resident (R)20, regarding blood pressure (BP-the amount of force your blood uses to get through your arteries) parameters for this resident on anti-hypertensive (medication used to help control BP) medication.

Inspectors wroteThe facility reported a census of 29 residents with 13 residents sampled, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist identified and reported the facility's staff failure to obtain blood pressures (BP-the amount of force your blood uses to get through your arteries) for one Resident (R)20 prior to administering his anti-hypertensive medication (medication used to help control BP), as ordered.

Inspectors wroteThe facility reported a census of 29 residents with 13 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure nursing staff followed antibiotic stewardship for one of the five residents, Resident (R) 28, with a urinary tract infection with a microorganism resistant to the prescribed antibiotic.

Inspectors wroteThe facility reported a census of 31 resident with 13 selected for review, including three reviewed for accident hazards. Based on observation, record review, and interview, the facility failed to implement an intervention following a fall to prevent further falls for one of the sampled residents, Resident (R)20. Additionally, the facility failed to implement an intervention following a laceration (wound to the skin) to his head which required medical treatment out of the facility, after he bumped it on the corner of a television, located in the common television room of the facility.

Inspectors wroteThe facility reported a census of 31 residents, with 13 residents sampled, including two sampled for discharge. Based on interview and record review, the facility failed to complete a discharge summary from the facility, which included a recapitulation of resident (R)33's stay at the facility.

Inspectors wroteThe facility identified a census of 31 residents with 13 selected for review including one resident reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure one sampled resident, Resident (R)1, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of his fingernails.

Inspectors wroteThe facility reported a census of 31 residents, with 13 residents sampled, which included three residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for Resident (R) 3, R 17, and R 28.

Inspectors wroteThe facility reported a census of 31 residents with 13 residents selected for review, including six residents reviewed for unnecessary medications. Based on interview and record review the facility failed to obtain physician ordered lab for Resident (R)24, and failed to schedule an appointment, failed to check blood sugar levels as ordered, and failed to obtain lab as ordered for R16.

Inspectors wroteThe facility reported a census of 31 residents with 13 residents sampled, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's recommendation in a timely manner, to resolve identified irregularities for two residents (R)17 related to potential duplicate therapy of respiratory treatment, dose reduction of medication used to treat pain and R 30 related to gradual dose reduction of psychoactive medication and obtaining lab recommendations.

Inspectors wroteThe facility reported a census of 31 residents, with 13 residents sampled, including six residents sampled for unnecessary medications. Based on record review and interview, the facility failed to notify the primary care provider on 16 occasions from 06/05/22 through 08/07/22 when R29's blood sugar level was out of ordered parameters.

Inspectors wroteThe facility reported a census of 31 residents with 13 selected for review including six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one of the sampled residents, Resident (R)1 was free unnecessary psychotropic (class of medications capable of affecting the mind, emotions, and behavior) medications.