Odelia Healthcare

Inspectors wroteBased on record reviews and interviews, the facility failed to provide a qualified interpreter for 1 (R #7) of 1 (R #7) residents reviewed. If a facility fails to provide interpreter services, then residents with limited English proficiency may not be able to fully understand their care plan, ask questions about their treatment, or communicate their needs effectively to staff.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the resident's MDS (MDS; a federally mandated assessment instrument completed by facility staff) was accurately coded for 1 (R #7) of 1 (R #7) residents reviewed. If the facility fails to ensure the Federally mandated MDS is accurately coded for residents, then the facility cannot develop appropriate care plans or provide individualized treatment, which places residents at risk for unmet needs, delayed interventions, and adverse health outcomes.

Inspectors wroteBased on a record review and interviews, the facility failed to ensure a resident received care for a diagnosis included on their hospital discharge paperwork for 1 (R #7) of 1 (R #7) residents. If the facility fails to ensure all admitting diagnoses are included in the resident's plan of care, then staff may fail to monitor and treat the condition which could lead to the adverse outcomes or re-hospitalization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Maintain the air gap on the ice machine in a manner to prevent contamination and foodborne illness, - Properly store open food with labels and dates to prevent cross contamination and outdated usage, - Sanitize dishes when staff did not maintain the dish washing machine at 120 degrees (°) Fahrenheit (F), per manufacturer's instructions, - Wash, rinse, and sanitize the food preparation sink between uses to prevent cross-contamination and the growth of food-borne pathogens, - Maintain the kitchen environment in a clean and sanitary manner, - Store clean dishes and single use plasticware in a manner to prevent contamination, - Thaw frozen food by submerging in cold running water. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility in a homelike manner when staff piled various items in an enclosed outside area near the facility. This failure had the potential to affect all residents who utilized the South 4 hallway, the Activities Room, and a courtyard near the Activities Room. If staff fail to maintain the facility in a homelike manner, then residents could feel unimportant and sad.

Inspectors wroteBased on record review, observation, and interview, the facility failed to place caution signs on the floor when the floor was wet. This failure had the potential to affect any resident who wanted to walk down the hallway. If staff fail to post caution signs on a wet floor, then residents could slip, fall, and injure themselves.

Inspectors wroteBased on record review and interviews, the facility failed to implement pharmacist recommendations for 1 (R #26) of 3 (R #9, #26 and #67) residents reviewed for unnecessary medications when staff failed to ensure R #26 had lab work completed. This deficient practice is likely to result in more than minimal harm because if residents lab work is not current then residents are likely to reach toxic levels of lithium (a mineral) or may not be receiving the correct dosage for therapeutic effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #37) of 1 (R #37) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 1 (R #31) of 1 (R #31) resident reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure staff administered a resident's tube feeding (feeding tube; a medical device used to provide nutrition to individuals who cannot eat or drink normally) according to physician's orders for 1 (R #23) of 1 (R #23) resident. This failure could potentially cause a resident not to receive enough daily nutrition and lose weight.

Inspectors wroteBased on observation, record reviews and interviews, staff failed to request a new provider medication order and to ensure drug records were accurate for 1 (R #45) of 1 (R #45) residents. This deficient practice is likely to lead to potential drug misuse or diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure meals were served at an appetizing temperature for 2 (R #59 and R #33) of 2 (R #59 and R #33) resident reviewed for meal quality. This deficient practice may decrease the resident's quality of life and have the potential to cause weight loss due to the food not being the proper temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in longer waits for meal service for any resident receiving a room tray during the three meals served at the facility. A. Record review of the facility's meal times revealed the following: - Breakfast 7:00 am to 8:30 am. - Lunch 12:00 pm to 1:30 pm. - Dinner 5:00 pm to 6:30 pm. B. On 05/27/25 at 2:46 pm, during an interview, R #28 stated meals were served late to his room three to four times a week. R #28 stated staff served meals up to an hour late sometimes. R #28 stated staff served the dinner room trays around 7:00 pm on 05/26/25. C. On 05/28/25 at 11:52 am, during an interview with R #24 and R #25, R #25 stated the food came out cold a lot of the time. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent staff to resident exploitation when a staff member used a resident's bank debit card to make an unauthorized (without the account holders permission) money withdrawal or purchases for 1 (R #1) of 1 ( R #1) resident looked at for abuse, neglect, and misappropriation. This deficient practice caused undue stress and anxiety for the resident when it was discovered they had money missing.

Inspectors wroteBased on record review and interview, the facility failed to readmit 1 (R #1) of 1 (R #1) resident back to the facility after being sent to the hospital for evaluation and treatment. This deficient practice is likely to result in a resident experiencing anxiety, confusion, and despair over not being allowed to return to their residence.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, resident representatives, and Ombudsman received a written notice of transfer as soon as practicable for 1 (R #1) of 1 (R #1) residents sampled for being discharged . This deficient practice could likely result in the resident representatives not knowing the reason for discharge, location of the resident, and when the resident can return to the facility.

Inspectors wroteBased on observations and interviews the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies. 3. Ensure all medication carts were locked when not in use. These deficient practices are likely to result in all 114 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication, having expired medical supplies used in their treatments, and allowing access to medication carts to unauthorized personnel.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures by: 1. Not performing hand hygiene between resident medication pass. 2. Not performing hand hygiene between collecting resident breakfast trays and passing out resident breakfast trays. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) for all of the 114 residents who resided at the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide accommodation of residents' needs for 3 (R #1, R #11, and R #111) of 3 (R #1, R #11, and R #111) residents reviewed for call lights within reach. This deficient practice is likely to result in residents being unable to request assistance, with activities of daily living, transfers after falling, or other acute distress.

Inspectors wroteBased on interview and record review, the facility failed to provide quality care for 2 (R #65 and #115) of 2 (R #65 and 115) residents by not following physician orders to get STAT (immediately) x-rays. These deficient practices could likely cause a medical concern to go unidentified and untreated, causing the medical condition to worsen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident wore protective boots while in bed to prevent pressure wounds (damaged skin caused by pressure, shear, or friction) for 1 (R #96) of 4 (R #10, 26, 50, and 96) residents reviewed for pressure ulcers. This deficient practice could likely result in the wound on the resident's heel to worsen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the recommended humidified oxygen (a device used to increase the level of moisture) for resident's comfort for 2 (R #1 and R #64) of 2 (R #1 and R #64) residents reviewed for oxygen therapy. This deficient practice of not providing humidified oxygen to a resident may likely result in a moisture deficit that naturally occurs when breathing through the nose and mouth and in a feeling of discomfort from irritation of throat and nose caused by administration of pure oxygen.

Inspectors wroteBased on observation and interview, the facility failed to safeguard clinical record information when they left protected health information (PHI; protected health information) unattended. This deficient practice had the potential to affect 1 (R #44) of 1 (R #44) (residents were identified by the Resident Census List provided by the Administrator on 01/09/24). If resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed by unauthorized residents, visitors, or staff.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality care when staff failed to disconnect, flush, and clamp a PICC line (peripherally inserted central catheter; a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near your heart) after an antibiotic (medication used to treat infections) infusion (putting the medication into the body through the PICC line) for 1 (R #96) of 1 (R #96) resident sampled for PICC lines. This deficient practice could likely result in the PICC becoming occluded (blocked), which would not allow medications to be infused, and the resident would not receive needed medications.

Inspectors wroteBased on record review and interview, the facility failed to provide proper foot care for 1 (R#42) of 1 (R#42) resident reviewed for foot care. This deficient practice is likely to cause pain, tenderness, and complications in foot health.

Inspectors wroteBased on record review, observation, and interview the facility failed to recognize a resident's deteriorated (to become worse) health status and immediately notify the Medical Provider of a change in condition for 1 (R #33) of 1 (R #33) resident reviewed for a change in condition. If the facility it not actively monitoring resident changes and notifying the Medical Provider in a timely manner, then residents are likely to not receive the care and interventions needed to maintain their highest practical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control practices by: 1. Not covering clean linens (microfiber cloths, bed comforters and covers) and physical therapy harnesses/slings (adaptive equipment used to safely lift a person or parts of their body during physical therapy). 2. Staff transporting soiled (dirty) linens carried in arms and pressed against staff's uniform, 3. Transporting soiled linen through a clean area, 3. Mixing soiled linen with clean linen, 4. Allowing build-up and accumulation of dust and lint on air conditioning vent of laundry folding room, and 5. Using torn cover on a clothing rolling garment rack. These deficient practices could likely affect all 117 residents in the facility as identified on the census list provided by the Administrator on 09/19/22. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that cleaning products were inaccessible to residents and that bottles were appropriately labeled according to the product inside the bottle. This deficient practice has the potential to effect all 117 residents per the facility census provided by the Administrator on 09/19/22, by putting residents at risk of harming themselves by accessing harmful chemicals and cleaning solutions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) care for 3 ( R # 8, #21 and #82) of 4 (R #8, #21, #30, and #82) residents reviewed for ADL care by not providing: 1. Eating assistance for R #8. 2. Grooming care of the fingernails for R #21. 3. Showers per resident choice for R #82. These deficient practices could likely cause weight loss due to needing assistance with eating, increased infections caused by tears in the skin from long and unclean fingernails, and increased infections and feelings of anger and depression from not being able to shower, according to resident's preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan for 1 (R #76) of 1 (R #76) resident reviewed for care planning following a fall. This deficient practice may likely result in staff confusion regarding best practices for the care of a resident who was at risk for falls and also preventing the resident from reaching their highest level of well-being.

Inspectors wroteBased on interview, and record review the facility failed to re-assess 1 (R #56) of 1 (R #56) resident for safe smoking. This deficient practice could likely contribute to an accident if residents are not being re-assessed to be safe to smoke without supervision.