Odd Fellow-Rebekah Home

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R2) was safely transferred out of three residents reviewed for transfers in a sample list of five residents. Findings Include:R2's Care Plan initiated 5/29/26 documents the following diagnoses: Encephalopathy, Seizures, Heart Disease, Dementia, Depression, Normal Pressure Hydrocephaly with Shunt, and history of a Cerebral Infarction. This Care plan included an intervention dated 5/27/25 Transfers: Sit-to-Stand transfer. Please use two staff members to assist with proper position related to my stroke history. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and dependent on staff for Activities of Daily Living (ADLs). On 7/21/26 at 11:47AM, V3 (R2's) family member stated I have a camera set up in (R2's) room. Whenever anyone enters the room I get a message. [...]

Inspectors wroteBased on interview and record review the facility failed to provide prompt complete catheter care to one resident (R2) of three residents reviewed for incontinence care in a sample list of five residents. Findings Include:R2's Care Plan initiated 5/29/26 documents the following diagnoses: Encephalopathy, Seizures, Heart Disease, Dementia, Depression, Normal Pressure Hydrocephaly with Shunt, and history of a Cerebral Infarction. This Care plan included an intervention dated 5/27/25 Transfers: Sit-to-Stand transfer. Please use two staff members to assist with proper position related to my stroke history. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and dependent on staff for Activities of Daily Living (ADLs). On 7/21/26 qt 11:47AM, V3 (R2's) family member stated V3 came to see R2 and R3 on Sunday 7/19/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (R1) was free from physical abuse from another resident (R2). This failure caused R1 to sustain a nasal fracture, a facial laceration requiring sutures to close, and bilateral hematomas to her eyes. Findings Include: R2's Care Plan, updated 6/16/26, includes the following diagnoses: Dementia, Hypertension (HTN), Hyperlipidemia, Pseudobulbar Affect, Seizure Disorder, and Aneurysm of the Aortic Arch. The Care Plan includes a problem initiated on 1/14/25 documenting that R2 has physical behavioral symptoms, including pulling others' hair, shoving or hitting others, and throwing items at others. The Care Plan also documents verbal behavioral symptoms, including yelling and growling at others. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement a baseline careplan for one (R2) resident, failed to implement fall interventions for three (R2, R3, R4) residents, failed to ensure the safety of one (R3) resident and failed to complete comprehensive fall investigations for three (R2, R3, R4) residents out of three residents reviewed for Accidents in a sample list of ten residents. R3 obtained five sutures to her forehead and a Subdural Hematoma due to an unwitnessed fall at the facility. R3 was transported to the emergency room to undergo diagnostic testing, laboratory work and full assessments from hospital staff. R3 experienced pain due to falling off her bed that was in high position.

Inspectors wroteBased on interview and record review, the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for one (R6) of three residents reviewed in a sample of nine.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two (R4, R6) of three residents reviewed for abuse in the sample list of 7. This failure resulted in R4 sustaining a fracture to her right wrist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement care plan interventions for a resident who required her bed to be maintained in the lowest position when in bed. This failure resulted in a fall for one (R3) of three residents reviewed for accidents. R3 sustained soft tissue swelling around the left eye and a 2-centimeter (cm) laceration above left eyebrow, requiring emergency room treatment and wound closure with adhesive glue. Findings Include:The facility's Fall Assessment and Management Policy dated 11/30/2012 with a revision on 6/2024 documents that it is the policy of the facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the state an allegation of resident-to-resident abuse for two (R4, R6) out of three residents reviewed for abuse, on a sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to investigate allegations of resident-to-resident physical abuse for two (R4, R6) out of three residents reviewed for abuse, on a sample list of seven.

Inspectors wroteBased on interview and record review, the facility failed to acquire, obtain, provide, and dispense prescribed medications for one resident (R3) of three reviewed for medications on a sample list of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was free from a significant medication error involving an anti-seizure medication. This failure affected one resident (R2) out of three reviewed for anti-seizure medications on the sample list of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate urinary incontinence care for resident cleanliness. This failure affects ten residents (R2, R3, R5, R10, R52, R57, R77, R92, R94, R111) out of twenty-five residing on the facility [NAME] Hall on the sample list of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents' nurse call lights within reach of residents requiring staff assistance. This failure affects two residents (R5 and R57) out of nine reviewed for dignity and activities of daily living on the sample list of 45.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a physician order for and assess a physical restraint placed on one (R62) resident out of two residents reviewed for restraints in a sample list of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during wound care for one (R46) out of three residents reviewed for wound care in a sample list of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during pressure ulcer care for one (R11) resident out of two residents reviewed for pressure ulcers in a sample list of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to wear appropriate Personal Protective Equipment (PPE) when providing wound care for one (R46) resident on Enhanced Barrier Precautions (EBP) out of one resident reviewed for isolation precautions in a sample list of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide palatable foods for four residents (R1, R4, R6, R7) out of four residents reviewed for Dietary Services in a sample list of ten residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal hygiene and showers timely for two residents (R1, R2) out of three residents reviewed for Activities of Daily Living (ADL) in a sample list of ten residents.

Inspectors wroteBased on observation, interview and record review the facility failed to complete a wound assessment, monitor skin integrity, and prevent cross contamination during wound care and incontinence care for three of three residents (R1, R2, R3) reviewed for pressure sores in the sample list of ten residents.

Inspectors wroteBased on observation, interview and record review the facility failed to wear the appropriate Personal Protective Equipment (PPE) during pressure ulcer care for two (R2, R3) residents on Enhanced Barrier Precautions (EBP) out of three residents reviewed for pressure ulcers in a sample list of ten residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R2, R3) reviewed for abuse in the sample list of five. Findings Include:The Facility Abuse Prevention and Reporting policy effective 3/15/2018, documents this facility affirms: 1. All residents have the right to be free of from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for trauma/abuse for one of three residents (R2) reviewed for abuse in the sample list of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician ordered treatment and services for a non-pressure abdominal wound. This failure affects one resident (R1) out of three reviewed for skin conditions and treatments on the sample list of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician ordered treatments and services to aid in the healing of a pressure ulcer. This failure affects one resident (R1) out of three reviewed for skin issues and treatments on the sample list of five.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the prescriber and in a timely manner for four of four residents (R1, R2, R3, R4) reviewed for medication administration in a sample list of eleven.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean homelike environment by failing to maintain clean walls and repair broken floor tiles in the facility's [NAME] shower room. This failure affects 49 residents (R1-R49) reviewed for homelike environment in the sample list of 49.

Inspectors wroteBased on interview and record review the facility failed to develop post fall interventions and treatment for a resident on anticoagulant therapy with head injury (R171), failed to implement careplan interventions for a resident (R171) post fall, failed to complete fall risk assessments and failed to thoroughly investigate falls for a resident (R67). These failure affects two (R171, R67) out of five residents reviewed for falls in a sample list of 75 residents. These failures resulted in R171, who was receiving anticoagulants, falling and sustaining a subdural hematoma.

Inspectors wroteBased on interview and record review the facility failed to maintain a resident's nutritional status and prevent significant weight loss by failing to implement nutritional supplements recommended by the dietician, and failing to notify the physician and dietician when significant weight loss continued. This failure resulted in R36 continuing to lose a significant amount of weight over one months time. This failure affected one of two residents (R36) reviewed for nutrition on the sample list of 75. Findings Include: The facility's Weight Management Policy and Procedure dated 2023 documents all residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. Any resident with a significant weight change will be referred to the dietitian for assessment of the resident's condition. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer physician prescribed medications to one (R321) resident out of five residents reviewed for significant medication errors in a sample list of 75 residents. R321 experienced Gastrointestinal (GI) upset, malaise and was hospitalized as a result of R321 missing multiple doses of medications for blood glucose control and Gastroesophageal Reflux Disease (GERD).

Inspectors wroteBased on interview and record review, the facility failed to provide follow-up care for residents who continued to have behaviors despite non-pharmacological interventions being used for four residents (R9, R16, R101, R104) and failed to refer a resident (R18) to behavioral health services after R18 made a suicidal statement. These failures affected five residents (R9, R16, R18, R101, R104) out of six residents reviewed for behavioral health services in a sample list of 75 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure only licensed personnel had access to the west hall medication room keys. This failure had the potential to affect all 46 of 46 residents (R1, R2, R3, R6, R7, R8, R10, R11, R13, R17, R18, R23, R25, R26, R29, R30, R33, R42, R45, R48, R50, R53, R54, R57, R60, R62, R63, R65, R70, R72, R74, R76, R77, R79, R81, R84, R85, R86, R93, R100, R103, R105, R113, R143, R152, and R321) reviewed for west hall, medication storage on the sample list of 75.

Inspectors wroteBased on observation, interview and record review the facility failed to wear the appropriate Personal Protective Equipment (PPE) during medication administration for a resident (R224) on Contact Isolation Precautions, failed to properly dispose of contaminated PPE for a resident (R321) on Enhanced Barrier Precautions (EBP), failed to complete hand hygiene during wound care and catheter care for a resident (R26) on EBP and failed to wear the appropriate PPE during incontinence care and catheter care for a resident (R17) on EBP. These failures affect four (R17, R26, R224, R321) out of four residents reviewed for infection control in a sample list of 75 residents.

Inspectors wroteBased on interview and record review the facility failed to notify a residents Physician timely for the residents fall with injury. This failure affects one (R171) out of five residents reviewed for falls in a sample list of 75 residents.

Inspectors wroteBased on interview and record review the facility failed to complete a recapitulation of stay for one (R118) resident out of one resident reviewed for discharge in a sample list of 75 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to apply physician ordered compression stocking for one of one residents (R81) reviewed for edema on the sample list of 75.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and monitor (R10, R18) pressure ulcers and failed to provide (R26) a pressure relief chair cushion. These failures affected three of six resident (R10, R18, R26) reviewed for pressure ulcers on the sample list of 75.

Inspectors wroteBased on observation, interview and record review the facility failed to implement care plan interventions and failed to label enteral feeding bottles for two (R84, R321) out of two residents reviewed for Gastrostomy tubes (G-tube) in a sample list of 75 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications per the physician order for one (R321) resident out of five residents reviewed for medication administration in a sample list of 75 residents. This failure resulted in two medication errors out of 26 opportunities, 7.69% medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure for the dignity of residents during incontinence care. This failure affects two (R1, R7) out of five residents reviewed for Activities of Daily Living (ADL) in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) for two (R1, R7) residents out of five residents reviewed for ADL's in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care for one (R1) resident out of five residents reviewed for incontinence cares in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to obtain a consent and initial assessment for an antipsychotic, psychotropic medication for one (R1) of three residents reviewed for psychotropic medications.

Inspectors wroteBased on interview and record review the facility failed to provide consistent oral/dental care for a dependent resident. This failure affected one of three residents (R1) reviewed for oral care in the sample of three. Findings Include: The facility's Morning Care policy dated April 2009 documents staff are to provide personal hygiene in the morning. Staff are to provide or assist residents with oral hygiene which includes oral care and cleaning dentures. R1's Medical Diagnoses List dated January 2024 documents R1 is diagnosed with Cerebral Infarction, Hemiplegia and Hemiparesis Left Side, Aphasia, Heart Failure, Muscle Weakness, Insomnia, Tremor, and Depression. R1's Care Plan dated 11/8/23 documents R1 has upper dentures and natural lower teeth and requires assistance with oral care, teeth brushing, and denture care. [...]

Inspectors wroteBased on observation. interview, and record review the facility failed to implement interventions to prevent a pressure ulcer and failed to assess and treat a facility acquired pressure ulcer for a resident. These failures affect one resident (R265) of three residents reviewed for pressure ulcers in a sample list of 58 residents. These failures caused R265 to develop two facility acquired unstageable pressure areas and an additional stage II pressure area.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe transfer and implement care plan interventions for three (R87, R265, R39) of eight residents reviewed for Accidents in a sample list of 58 residents. These failures resulted in R39 sustaining an upper arm (Right Humeral) fracture and pelvic (Inferior Pubic Ramus) fractures and R87 sustaining pelvic (Superior and Inferior Pubis Rami) fractures. R39 and R87 required emergency services and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent potential cross contamination of foods served during meal service. This failure has the potential to affect all 117 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to notify the State Ombudsman for one (R87) of four residents reviewed for hospitalizations in a sample list of 58 residents.

Inspectors wroteBased on interview and record review the facility failed to provide a Bed Hold Policy to three (R39, R63, R87) of four residents hospitalized in a sample list of 58 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to label a date opened on residents eye drops/ointments. This failure affects five residents (R33, R25, R66, R12, R9) reviewed for medication storage in the sample list of 58.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain respiratory care tubing and masks in a clean sanitary manner for three residents (R260, R44, R9) of three residents reviewed for respiratory care in a sample list of 58 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of three (R5, R65, R71) of three residents reviewed for dignity in a sample list of 58 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to complete a restraint assessment and obtain an order for a restraint prior to use for one of two residents (R56) reviewed for restraints in the sample list of 58. Findings Include: The facility's Restraint Program Policy and Procedure with a revised date of 11/10/15 documents, 1. Prior to the use of any restraint, (unless the restraint is used in an emergency situation) each resident is assessed for potential alternatives by using the restraint Pre-Restraining and Quarterly Evaluation UDA (User-Defined Assessments). 2. Documentation of alternatives are then listed in the resident's plan of care. 6. Reduction attempts are documented. Some examples of interventions may include, but are not limited to: a. Therapy consultation b. Environmental modifications c. Positioning d. Activity programming e. Toileting programming. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report an injury of unknown origin to the state agency within two hours of discovering the injury for one of one (R68) resident reviewed for abuse on the sample list of 58.

Inspectors wroteBased on interview and record review the facility failed to include the cleaning and maintenance of a Continuous Positive Airway Pressure (CPAP) machine on the Care Plan for one (R260) of 24 residents reviewed for Care plans in a sample list of 58.

Inspectors wroteBased on interview and record review the facility failed to update a resident's care plan with weight loss for one of 24 residents (R56) reviewed for care plans in the sample list of 58.

Inspectors wroteBased on interview and record review the facility failed to implement restorative nursing services for ambulation following discharge from therapy services for one of one residents (R56) reviewed for range of motion in the sample list of 58.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide behavioral health care and services for a resident having frequent crying episodes. This failure affects one of one (R66) residents reviewed for mood on the sample list of 58.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R65, R258) reviewed for medication administration in the sample list of 58. The facility had 2 medication errors out of 29 opportunities resulting in a 6.9% (percent) medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to honor food preferences for two (R30, R35) out of two residents reviewed for food preferences in a sample list of 58 residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately encode the Minimum Data Set Resident Assessment Instrument for falls experienced by a resident. This failure affects one resident (R3) out of four reviewed for falls on a sample of four.

Inspectors wroteBased on record review and interview, the facility failed to complete an initial, or subsequent, Abnormal Involuntary Movement Scale for a resident receiving antipsychotic medications. This failure affects one resident (R3) out of four reviewed for falls on a sample of four.