Oswego Operator, LLC

In the surveyor’s words

From the most serious findings on record at Oswego Operator, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 7, 2021

  The facility reported a census of 34 residents with three residents sampled for accidents. Based on record review and interview, the facility failed to ensure appropriate and safe transfer of one of the three residents sampled, Resident (R) 1, who required a mechanical lift with a sling to move from surface to surface. On 06/21/21, staff used an inappropriate sized mechanical lift sling, rated to hold 250 pounds (lbs) when the resident weighed 422 lbs. Subsequently during the transfer, the straps of the sling broke and caused the resident to fall approximately 2-3 feet to the floor, landing on his back. The staff lacked the appropriate knowledge of how to read the labels correctly on the slings and assumed all slings in the facility held a maximum of 600 lbs. […]

• Actual harm, isolatedF689Aug 16, 2022

  The 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. […]

• No harm, potential for more than minimal, widespreadF812Dec 30, 2025

  The 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… […]

• No harm, potential for more than minimal, widespreadF924Dec 30, 2025

  The 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. Findings included:- Observed on 12/28/25 2:15 PM, there was a total of four loose handrails in the north resident hall. Observed on 12/29/25 at 09:53 AM, five handrails on the east resident hall were loose. There were three handrails on the south resident hall that were loose. Observed on 12/30/25 at 10:20 AM, administrative staff were checking the handrails throughout the building and marking those handrails that were loose for residents and staff to safely identify. […]

• No harm, potential for more than minimal, widespreadF851May 20, 2024

  The 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. […]