Odd Fellow Home

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 resident (R) (R15) of 3 sampled residents was appropriately supervised to prevent accidents and abuse. R15 wandered in the facility and into residents' rooms uninvited. On 7/6/26, R15 wandered into R4's room, looked through their personal belongings, and hit them on the arm. R15's care plan did not contain appropriate interventions and levels of supervision to prevent future occurrences.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R1) of 4 sampled residents. R1 was prescribed Eliquis (blood thinning medication) 2.5 milligrams (mg) twice daily for one week following surgery. The dose was to be increased to 5 mg twice daily on 12/26/25. The dose was not increased until 12/27/25 which resulted in R1 receiving two incorrect doses of the medication. The facility's Administering Medications policy, revised 12/10/25, indicates: Medications should be administered in accordance with prescriber's orders. On 2/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including post-hip arthroplasty, osteoarthritis, atrial fibrillation, and panic disorder. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not report allegations of abuse to the State Agency (SA) for 2 residents (R) (R1 and R8) of 2 sampled residents. R1 had a witnessed fall on 10/17/25. The facility determined abuse occurred. The facility's 5-day investigation was not submitted to the SA within the required timeframe. R8 reported that a Certified Nursing Assistant (CNA) was abusive to R8. The facility initiated a grievance form but did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 2 residents (R) (R1 and R8) of 2 sampled residents. R1 fell on [DATE]. The facility determined abuse occurred. The allegation of abuse was not thoroughly investigated and inaccurate staff education was provided. R8 reported a Certified Nursing Assistant (CNA) was abusive to R8. The allegation of abuse was not thoroughly investigated.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure administration of medication in accordance with physician orders for 1 resident (R) (R2) of 1 sampled residentR2's AM and PM medications were administered late on multiple occasions.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility did not ensure fall interventions were in place for 1 resident (R) (R1) of 4 sampled residents. R1 was assessed to be at high risk for falls and had a history of falls. R1's care plan contained interventions for fifteen-minute safety checks and grip strips on the floor near R1's bed. The interventions were not consistently implemented.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 59 residents residing in the facility. IP-C and Director of Nursing (DON)-B shared infection prevention duties for the facility since of March 2025. IP-C did not complete specialized training and DON-B had not begun specialized training. Nursing Home Administrator (NHA)-A indicated a permanent IP was hired and had started infection prevention and control training on 5/5/25.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 8 residents (R) (R13, R30, R26, R46, R14, R263, R20, and R0) in 1 of 2 medication carts were labeled and/or dated appropriately. In addition, the facility did not ensure expired treatment supplies were removed from storage in 1 of 4 medication storage areas and did not ensure medication was stored appropriately. Medication was left unattended on top of the medication cart. A medication storage area contained undated and expired resident and stock medications and medical supplies. A medication cart contained unlabeled, undated, and expired resident and stock medications.

Inspectors wrote2. R39's medical record indicated R39 had chronic diabetic wounds. On 5/5/25 at 10:40 AM, Surveyor observed 3 staff (2 therapy staff and one CNA) transfer R39 without wearing PPE. R39's room did not contain a sign on or near the door that indicated R39 was on EBP. On 5/6/25 at 8:15 AM, Surveyor noted an EBP sign was on R39's door. On 5/6/26 at 10:26 AM, Surveyor interviewed DON-B who indicated PPE should be worn during high-contact cares such as hygiene, dressing, linen changes, and cares involving open areas and and body fluids for residents who are on EBP. DON-B indicated residents with wounds should be on EBP and confirmed R39 should be on EBP. On 5/6/25 at 1:07 PM, Surveyor observed CNA-R assist R39 to the restroom without PPE. When Surveyor asked CNA-R if PPE was required, CNA-R indicated no because R39 did not have any open wounds. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was submitted for a Level II Screen when a 30-day hospital exemption expired for 2 residents (R) (R56 and R49) of 18 sampled residents. R56 and R49 were identified on their PASRR Level I Screens as suspected of having a serious mental illness. The facility did not submit for PASRR Level II Screens when R56 and R49's 30-day hospital exemptions expired.

Inspectors wroteBased on staff interview and record review, the facility did not ensure ongoing communication with the dialysis center or ensure ongoing monitoring of the fistula site for 1 resident (R) (R6) of 1 sampled resident. R6 received dialysis three times weekly. The facility did not ensure ongoing communication with the dialysis center or routinely monitor R6's fistula site.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R13) of 4 residents observed during medication administration During the AM medication pass on 5/5/25, R13 received Senna-Plus instead of Senna.

Inspectors wroteBased on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 3 residents (R) (R19, R122, and R264) of 6 sampled residents. R19 did not meet McGeer's criteria for a urinary tract infection (UTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R19 did not meet the criteria for a UTI. R122 did not meet McGeer's criteria for a skin and soft tissue infection (SSTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R122 did not meet the criteria for an SSTI. R264 did not meet McGeer's criteria for a respiratory tract infection (RTI) but received antibiotic therapy. [...]

Inspectors wrote[NAME] 1/9/25 Based on observation, staff interview, and record review, the facility did not ensure care plans were reviewed and revised for 3 residents (R) (R11, R5, and R3) of 13 sampled residents. R11, R5, and R3's care plans were not updated with interventions related to leaving Hoyer slings underneath R11, R5, and R3.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the adequate use of assistive devices to prevent injury for 1 resident (R) (R3) of 2 sampled residents. R3 indicated the lift battery often died while R3 was mid-transfer and R3 was left hanging in the lift while staff replaced the battery.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate care and services for 2 residents (R) (R10 and R12) of 6 sampled residents with an indwelling catheter. On 1/9/25, R10 and R12's catheter drainage bags were observed in contact with the floor.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a prescribed diet was followed for 1 resident (R) (R3) of 3 sampled residents. R3 was prescribed a consistent carbohydrate hydro-oligomeric diet (CCHO) (a diet designed to manage blood sugar levels in individuals with diabetes or prediabetes). R3's diet order was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R13) of 13 residents observed during the provision of cares. R13 was on enhanced barrier precautions (EBP) which required staff to wear personal protective equipment (PPE) during high-contact cares. On 1/9/25, staff transferred and provided wound care for R13 without wearing PPE. In addition, Surveyor observed staff exit R13's room with a vital signs machine. Staff did not appropriately disinfect the machine after use.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R5 and R6) of 13 sampled residents. The facility did not report a resident-to-resident altercation between R5 and R6 to the State Agency (SA) in a timely manner because staff did not report the incident timely to administration. The facility could not provide proof of education for the staff who were working when the resident-to-resident altercation occurred.

Inspectors wroteBased on observation and staff interview, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all 50 residents residing in the facility. On 3/10/24, the lids on 3 outside refuse dumpsters were open and there was garbage on the ground.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 50 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: Describe the building's water system using text and an accurate flow diagram of the system; Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread; [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not promote and facilitate resident self-determination for 6 Residents (R) (R1, R4, R10, R25, R27, and R39) of 6 residents. Staff did not allow R1, R4, R10, R25, R27 and R39 to make choices regarding their meals.

Inspectors wroteBased on staff and resident interview and record review, the facility did not make a prompt effort to resolve grievances for 5 Residents (R) (R210, R211, R28, R209 and R13) of 7 sampled residents. R210 reported to staff that R210 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. R211 reported to staff that R211 was missing a nightgown. The facility did not resolve the grievance in a timely manner. R209 reported to staff that R209 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. R28 reported to staff that R28 was missing bed linens. The facility did not resolve the grievance in a timely manner. R13 reported to staff that R13 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. Certified Nursing Assistant (CNA)-J's background check information did not contain an out-of-state criminal or caregiver background check.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R204, R36, and R19) of 4 residents reviewed for hospitalizations received a written notice of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of the transfers. R204 was transferred to the hospital on 2/27/24. R204 was not provided a written transfer notice and the Ombudsmen was not notified of the transfer. R36 was transferred to the hospital on [DATE] and 11/27/23. R36 was not provided written transfer notices and the Ombudsmen was not notified of the transfers. R19 was transferred to the hospital on [DATE] and 2/27/24. R19 was not provided written transfer notices and the Ombudsmen was not notified of the transfers.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R204, R36 and R19) of 4 residents reviewed for hospitalizations received written information of the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility. R204 was transferred to the hospital on 2/27/24 and was not provided a copy of the facility's bed hold policy. R36 was transferred to the hospital on [DATE] and 11/27/23 and was not provided copies of the facility's bed hold policy. R19 was transferred to the hospital on [DATE] and 2/27/23 and was not provided copies of the facility's bed hold policy.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure each resident received adequate supervision and assistive devices, did not ensure fall assessments were completed, and did not ensure interventions to prevent falls were implemented for 2 Residents (R) (R12 and R19) of 18 sampled residents. On 3/11/24, staff used a lift with defective brakes and a defective sling to transfer R12. Staff did not appropriately assess R19 following a fall with head injury on 2/26/24. In addition, the facility did not update R19's care plan with interventions to prevent future falls.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R34) of 1 resident received the necessary care and services for respiratory therapy. The facility provided R34 with respiratory therapy via CPAP (continuous positive airway pressure) without a physician's order. In addition, R34's need for and use of CPAP therapy was not care planned for assessment, evaluation, or monitoring.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of a high risk medication was provided for 1 Resident (R250) of 5 residents reviewed for unnecessary medication. R250 had physician orders for short-acting and long-acting insulin (used to treat high blood sugar). R250's plan of care did not contain interventions to monitor R250 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 50 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open or use-by dates. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not properly heat food in the microwave that was served to residents. Staff did not follow safe food cooling protocols. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did not perform appropriate hand hygiene and safe food handling practices while cooking and serving food

Inspectors wroteBased on staff interview and record review, the facility did not ensure it completed mandatory submission of staffing information based on payroll data in a uniformed format to the Centers for Medicare & Medicaid Services (CMS). This practice had to the potential to affect all 50 residents residing in the facility. Staffing information for Quarter 1 (October 1-December 31), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30), and Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) was not submitted to CMS.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 of 5 Certified Nursing Assistants (CNAs) was eligible to work in a federally certified facility. This practice had the ability to affect multiple residents in the facility. CNA-I was employed by the facility. CNA-I was not currently eligible to work in federally certified nursing homes because CNA-I's certification had lapsed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not follow menu serving sizes, individualized diets, and food preparation recipes to ensure nutritional needs were met for multiple residents residing in the facility. During the 3/10/24 lunch meal, staff did not follow menu serving sizes for residents who received chicken drumstricks as their main entree. During the 3/11/24 lunch meal, staff did not follow R1, R4, and R10's individualized diets. During the 3/11/24 lunch meal, staff did not follow a recipe when making mashed potatoes for 4 residents who received pureed diets.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of neglect was thoroughly investigated for 1 Resident (R) (R204) of 1 sampled resident. The facility did not thoroughly investigate R204's allegation of neglect.

Inspectors wroteBased on observation and staff interview, the facility did not ensure the nurse staffing was posted daily and did not ensure the required information was on the posting. This practice had the potential to affect all 50 residents residing in the facility. During entrance to the facility on 3/10/24, Surveyor noted the nurse staff posting was dated 3/8/24. The facility did not consistently post the nurse staffing prior to the start of the shift and did not include the required information on the posting.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures to prohibit mistreatment, neglect and abuse of residents for 3 staff (Certified Nursing Assistant (CNA)-C, CNA-D and Registered Nurse (RN)-E) of 8 staff reviewed during the caregiver program compliance check. CNA-C was hired on 8/14/15. The facility did not have a current completed Background Information Disclosure (BID) form for CNA-C. CNA-D was hired on 2/28/19. The facility did not have a current completed BID form for CNA-D. RN-E was hired on 3/4/16. The facility did not have a current completed BID form for RN-E.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R2) of 9 residents. The facility did not conduct a thorough investigation of an allegation of abuse involving R2 when the facility did not prevent further potential abuse of R2 and other residents while the investigation was in progress. Certified Nursing Assistant (CNA)-F was not removed from resident care while the potential allegation of abuse was investigated. In addition, R2's plan of care was not changed as indicated by the facility.

Inspectors wroteBased on staff interview and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. This practice had the potential to affect all 52 residents residing in the facility. The facility did not conduct continuous infection surveillance including tracking and trending of illnesses, potential infectious agents, and monitoring of resident signs and symptoms of infection or potential infection. In addition, the facility did not maintain surveillance logs to help the facility recognize and track trends or patterns of infections and help prevent the spread of communicable diseases within the facility.

Inspectors wroteBased on staff interview and record review, the facility did not maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. This had the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the facility's Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 52 residents residing in the facility. IP-C started as the facility's designated IP on 8/22/22; however, IP-C did not complete specialized training for infection prevention and control until 2/20/23 and IP-C's employment at the facility ended on 2/27/23. Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Minimum Data Set Coordinator (MDS)-D became the facility's designated full-time IPs on 2/27/23; however, DON-B, NHA-A and MDS-D did not complete specialized training for infection prevention and control.

Inspectors wroteBased on staff interview and record review, the facility did not conduct testing of residents and staff consistent with current standards of practice for COVID-19 testing. This had the potential to affect all 52 residents residing in the facility. The facility did not initiate an outbreak investigation, conduct COVID-19 testing or complete contract tracing when a new case of COVID-19 was identified among residents or staff.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 Resident (R) (R26) of 13 sampled residents reviewed for safety. R26 did not have access to a call light when R26's door was closed and R26 was calling out for help.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident or resident's representative was provided education regarding the risks versus benefits of COVID-19 immunization and did not obtain consent or refusal for COVID-19 immunization for 1 Resident (R) (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation to indicate R29 or R29's representative was provided education by the facility regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization.