The Meadows at Osborn Park

In the surveyor’s words

From the most serious findings on record at The Meadows at Osborn Park, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 30, 2026

  Based on medical record review, hospital record review, resident, family, staff, physician, and agency staff interviews, review of staff statements, and review of the facility policy, the facility failed to ensure safe mechanical lift transfers and further failed to adequately assess, timely notify the physician and resident representative, address resident pain, and conduct a thorough investigation following a fall from a mechanical lift. This resulted in Actual Harm to Resident #36 when on the morning of 04/22/26, the resident fell during a mechanical lift transfer and was found to have sustained a displaced fracture of the distal femur and a distal fifth metacarpal fracture of the left hand. […]

• No harm, potential for more than minimal, widespreadF761Jun 25, 2026

  Based on observation, staff interview, medical record review, review of manufacturer instructions, and review of facility policy, the facility failed to store and manage medications safely, including improper dating, disposal, labeling of multi-does and insulin medications, and leaving medication carts unsecured. This had the potential to affect all 119 residents residing in the facility.Findings include: 1. Observation on 06/23/26 at 7:10 A.M. of the medication storage room for cluster one with Licensed Practical Nurse (LPN) #314 revealed the medication storage refrigerator contained one 16-ounce container of Marzetti ranch vegetable dip that was opened and approximately two-thirds full and one 2.76 ounce Hillshire Farms snacking tray that was unopened. […]

• No harm, potential for more than minimal, patternF689Jun 25, 2026

  Based on record review, review of the mechanical lift and mechanical lift slings manufacturer's instructions, observation, resident and staff interviews, and policy review, the facility failed to ensure residents were transferred safely following physician orders and ensure staff were monitoring the mechanical lift slings for signs of damage. This had the potential to affect 39 residents (#4, #6, #7, #8, #9, #11, #12, #15, #22, #32, #33, #34, #38, #42, #45, #48, #51, #54, #59, #60, #65, #72, #74, #75, #76, #77, #88, #90, #94, #95, #99, #100, #104, #107, #108, #109, #112, #118, and #119) who the facility identified as requiring the use of a mechanical lift for transfers. The facility census was 119.Findings include:1. […]

• No harm, potential for more than minimal, patternF803Jun 25, 2026

  Based on review of facility menus, record review, observations, and staff interviews, the facility failed to serve the correct food portions of pureed foods to the residents. This affected seven (#22, #32, #45, #60, #72, #74, and #104) of seven residents who were ordered pureed diets. The facility census was 119.Findings include:Review of the facility's spring menu revealed lunch being served on 06/23/26 consisted of three ounces of meatloaf.Observation and interview on 06/23/26 at 10:45 A.M. revealed [NAME] #391 prepared pureed meatloaf for residents and was using a two-and-a-half-ounce green scoop to portion the pureed food. [NAME] #391 revealed she planned to use a half-filled two-and-a-half-ounce green scoop to portion the pureed meatloaf into bowls. […]

• No harm, potential for more than minimal, patternF880Mar 3, 2021

  Based on observation, staff interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff donned and doffed personal protective equipment (PPE) appropriately to prevent the spread of infection. This affected three Residents (#08, #16, and #65) of four who who were dining in their room. Findings Include: Observation on 03/01/21 at 12:23 P.M., of the meal tray service revealed Licensed Practical Nurse (LPN) #100 was wearing a face shield and an N95 mask. LPN #100 put on a foot coverings, a gown, a hairnet and gloves, and took a tray off the cart and walked into the room of Resident #56, who was on a 14 day quarantine isolation, set the meal tray on the bedside table. […]