The Meadows At Osborn Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and policy review, the facility failed to provide a resident who was dependent on staff for showers/bathing received routine showers/bathing. This affected one (#64) of three residents reviewed for activities of daily living. The facility census was 119.Findings include:Review of Resident #64's medical record revealed an admission date of 08/28/25. Diagnoses included Parkinson's disease, major depressive disorder, weakness, anxiety, and muscle weakness.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had moderately impaired cognition and required partial or moderate assistance from staff with tub or shower transfers and for showering or bathing.Review of the care plan dated 05/28/26 revealed Resident #64 had an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance, limited mobility, and Parkinson's disease. Interventions included Resident #64 required moderate assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure nutritional interventions were implemented per physician order and the plan of care, for residents identified at nutritional risk. This affected two (#39 and #52) of three residents reviewed for nutrition. The facility census was 95. Findings include: 1. Review of Resident #52's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus without complications, iron deficiency, dementia, age-related osteoporosis, depression, anxiety, muscle weakness, and cognitive communication deficit. Review of Resident #52's current plan of care, revised 02/15/23, revealed the resident had a nutritional problem related to fracture of left femur, physical disability, fracture of left humerus, anemia, hypoosmolality/hyponatremia, therapeutic diet order for small portions per request, assist with meals, upper and lower dentures, history of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to maintain accurate medical records regarding documentation for nutritional supplements. This affected one (#52) of two residents reviewed for nutrition. The facility census was 95. Findings include: Review of Resident #52's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus without complications, iron deficiency, dementia, age-related osteoporosis, depression, anxiety, muscle weakness, and cognitive communication deficit. Review of Resident #52's current plan of care, revised 02/15/23, revealed the resident had a nutritional problem related to fracture of left femur, physical disability, fracture of left humerus, anemia, hypoosmolality/hyponatremia, therapeutic diet order for small portions per request, assist with meals, upper and lower dentures, history of falling, eats fifty-percent or less, advanced age, meal and/or supplement refusals, significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of dietary menus, review of dietary spreadsheets, and staff interviews, the facility failed to serve the identified portion sizes of pureed chicken to 12 residents (#4, #5, #9, #16, #23, #57, #59, #65, #76, #80, #93 and #94) who received pureed diets. The facility census was 119. Findings include: Review of the menu for the lunch meal on 02/03/20 identified the facility was serving chicken, mashed potatoes and green beans. Review of the spreadsheets for the lunch meal on 02/03/20 revealed pureed diets should receive a #10 scoop of pureed chicken. The facility provided a listing that identified size #10 scoop is equal to 3/8 cup or 3 ounce. Observation on 02/05/20 at 11:49 A.M., [NAME] #114 was plating the noon meal. [NAME] #114 was observed to be utilizing a two ounce scoop for the pureed chicken for each of the residents receiving pureed diets. Interview on 02/05/20 at 12:02 P.M., [NAME] #114 confirmed she was not aware the facility menus had portion sizes listed and she just uses the same scoops for each meal. Interview on 02/05/20 at 12:04 P.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, family interview, staff interview, and review of facility policy, the facility failed to ensure call lights were in reach for three (#45, #57, #65) of 24 residents reviewed for accommodation of needs. The facility census was 119. Findings include: 1. Review of medical record for Resident #45 revealed an admission date of 05/28/16. Diagnoses included hemiplegia and hemiparesis affecting left non-dominant side, Parkinson's disease, Alzheimer's disease, muscle weakness, ataxic gait, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/28/19, revealed Resident #45 was moderately cognitively impaired with behaviors that fluctuate in severity. Resident #45 was assessed as needing extensive assistance for function of bed mobility, transfers, and locomotion. The MDS revealed Resident #45 was assessed as needing extensive assistance for dressing, eating, toilet use, and personal hygiene. Observation on 02/03/20 at 09:53 A.M. revealed Resident #45 was sitting in a recliner with his back to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical records review, resident interview, and staff interview, the facility failed to honor resident choice on roommates and who to eat meals with for two (#62 and #85) of 24 sampled residents. The facility census was 119. Findings include: Review of Resident #62's medical records identified admission to the facility occurred on 11/19/19. Medical diagnoses included dysphasia, anemia, and schizo-affective disorder. The record identified prior to admission to the facility Resident #62 lived with her sister (Resident #85) in the community. Interview on 02/03/20 at 9:28 A.M., Resident #62 identified her sister, Resident #85, was admitted to the facility in December and she wanted to be roommates with her. Resident #62 identified the facility has not made any efforts to try to accommodate the residents' wishes to room together. Resident #62 also stated when her sister and her go to the dinning room they were not permitted to sit next to one another because she required staff to fed her meals. Resident #62 confirmed she would like to sit next to her sister while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, family interview, review of financial records, and staff interview, the facility failed provide the notice of bedhold policy upon discharge to the hospital for one (#166) of three residents reviewed for hospitalization. The facility census was 119. Findings include: Review of Resident #166's medical record identified admission to the facility occurred on 11/30/19. The record identified on 01/17/20 Resident #166 was sent to the hospital and admitted with a fractured hip. The record revealed a lack of bed hold policy notification at the time of hospital discharge. The record identified Resident #166 remained in the hospital from [DATE] through 01/22/20. Review of Resident #166's financial records revealed the resident paid privately for her nursing home stay. She was charged a bed hold for each day she was not in the facility during her hospital admission. Interview on 02/05/20 at 2:06 P.M., Fiscal Office [NAME] #71 stated she was only responsible to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, family interview, and staff interviews, the facility failed to ensure residents were invited to participate in their care planning meetings. This affected one (#166) of four residents reviewed for participation in care planning. The facility census was 119. Findings include: Review of Resident #166's medical record identified admission to the facility occurred on 11/30/19 following hospitalization. Diagnosis included pathological fractures of the right foot, The facility admission assessment dated [DATE] revealed Resident #166 was cognitively intact. The record contained no evidence Resident #166 had been invited to participate in care planning. Interview on 02/03/20 at 3:13 P.M., Resident #166 stated she had never been invited nor attended her care plan meetings, but would if she was asked. Interview on 02/05/20 at 9:18 A.M., Licensed Social Worker (LSW) #87 identified the Minimum Data Set nurse completed the schedule for care planning conferences and she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record review, and staff interviews, the facility failed to follow physician orders for the application of a boot to the lower extremity for one (#1) of five residents reviewed for skin conditions. The facility census was 119. Findings include: Review of Resident #1's medical record identified admission to the facility occurred on 06/17/17. Diagnoses included diabetes, peripheral vascular disease, above the knee amputation and hemiplegia. Review of Resident #1's physician orders identified the use of a zero gravity boot to the left foot at all times. Observation on 02/04/20 at 11:22 A.M. revealed Resident #1 was sitting in a tilt back wheelchair which had medal foot pedals on both sides of the chair. Resident #1 did not have a zero gravity boot on the left foot. Resident #1 left foot was turning into the right side and is toes were hitting the right foot pedal. Interview on 02/04/20 at 11:36 A.M., State Tested Nursing Assist (STNA) #48 confirmed Resident #1 should have a zero gravity boot on his left foot. The STNA stated she had placed the boot in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based of review of a nurse's note, review of a vision provider note, review of an Eye Glass Tracker form, review of a Vision Care form, staff interviews, and review of facility policy, revealed the facility failed to timely follow up with a vision care provider regarding ordered eye glasses not yet received. This affected one (#91) of one resident reviewed for vision care services. The facility census was 119. Finding included Review of the medical record revealed Resident #91 had an admission date of 02/07/18. Diagnoses included heart failure, dysphagia, major depressive disorder, and diabetes mellitus type two. Review of the annual Minimum Data Set (MDS) assessment, dated 01/01/20, revealed the resident had impaired cognition. Further review of the assessment noted resident had no corrective lenses. Review of a nurse's note dated 10/15/19 10:09 A.M. revealed laundry staff found the resident's eye glasses in the dryer. A screw was missing and one of the lenses was missing. Review of a vision provider note dated 10/17/19 revealed the resident was seen for a diabetic eye exam. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to notify the resident, the resident's representative and the Ombudsman of the transfer or discharge and the reason for a residents transfer/discharge in writing. This affected two (#126, #127) of three reviewed for discharge. The facility census was 125. FINDINGS INCLUDED: 1. Review of Resident #127's medical record revealed an admission date of 10/15/18 with diagnoses of chronic kidney disease stage five, dysphasia, diabetes mellitus, morbid obesity, chronic embolism and chronic respiratory disease with hypoxia. Review of Resident #127's medical record revealed the resident was discharged to the hospital on [DATE] due to shortness of breath and hypoxia. Resident #127 did not return to the facility. The facility form titled Discharge Tracking, which was used to notify the Ombudsman of the month's discharges, was reviewed. The form did not contain the name of Resident #127, therefore the Ombudsman was failed to be notified of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed to accurately reflect the residents status. This affected one (#2) of two (#2 and #1) resident MDS assessments reviewed. The facility census was 125. Findings include: Review of Resident #1's medical record revealed an admission date of 02/22/18. Diagnoses included lung cancer, urinary tract infection, and atrial fibrillation. Further review revealed the resident discharged from the facility on 09/19/18. Review of Resident #1's MDS assessments revealed a discharge assessment was not completed for the resident. Interview on 01/10/19 at 9:04 A.M., Registered Nurse (RN) #333 confirmed Resident #1 should have had a discharge assessment dated [DATE] completed and did not. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, chapter two, page two-34, dated 10/2014, revealed a discharge MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policy and staff interviews, the facility failed to ensure residents had a plan in place for discharge to the least restrictive environment. This affected one (Resident #31) of three residents reviewed for discharge. The facility census was 125. Findings include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis including Bipolar disorder. Review of progress notes dated 04/25/18 at 1:36 P.M., identified guardian told Resident #31 they would look at discharge after so many months of working. Review of a Care Conference Meeting Documentation dated 04/19/18 identified no evidence of anyone reviewing Resident #31's wishes for discharge plans being made. Review of progress notes dated 07/24/18 at 8:50 A.M. identified Resident #31 struggles with nursing home placement; no plan for discharge presently guardian does not want to be asked about it. The medical record identified no written plan of care for Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a discharge summary was completed and post discharge plan of care for one resident (Resident #126) of three sampled for discharge. The facility census was 125. Findings include: Record review revealed Resident #126 was admitted to the facility on [DATE]. Documented diagnoses listed for Resident #125 included pulmonary embolism, muscle weakness, unspecified lack of coordination, localized edema, acute post-hemorrhagic anemia, essential tremor, hypertensive heart disease, embolism and thrombosis of superficial veins of lower extremities, peptic ulcer, and malignant neoplasm of pancreas. Record review of skilled nursing revealed Resident #126 to be alert and oriented to person, place, time and situation. Resident #126 was under palliative care, had weakness noted for activities of daily living, and required assistance from staff for bed mobility, transfers, and toilet use. Review of discharge planning review form completed on 09/12/18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.