Inspection Reports for Odd Fellow Home

The complaint investigation involved two residents, R1 and R8. R1 had a witnessed fall and abuse was determined to have occurred, but the 5-day investigation report was submitted late. R8 reported abuse by a CNA, but the allegation was not reported to the State Agency and the investigation was incomplete. Staff education was inadequate. Both allegations were substantiated as the facility failed to meet reporting and investigation requirements.

The facility failed to timely report allegations of abuse for two residents and did not thoroughly investigate these allegations. Staff education on abuse was incomplete and inaccurate. Additionally, medication administration for one resident was frequently late, not in accordance with physician orders.

The investigation was complaint-related, focusing on fall prevention for resident R1. The report indicates the complaint was substantiated based on observations, interviews, and record reviews showing inconsistent implementation of fall prevention measures.

The facility failed to consistently implement fall prevention interventions for resident R1, who was at high risk for falls and had a history of multiple falls. Safety checks were not consistently completed, grip strips were not placed beside the bed, and staff did not always follow care plan interventions, resulting in an unwitnessed fall with injury.

The facility had multiple deficiencies including failure to submit PASRR Level II screens after hospital exemptions expired for two residents, inadequate dialysis site monitoring and communication, medication administration errors, improper medication labeling and storage, lapses in infection prevention and control practices, early return to work of staff with COVID-19 and GI symptoms, incomplete antibiotic stewardship, and lack of a fully trained infection preventionist.

The facility was found deficient in multiple areas including failure to update care plans for residents regarding leaving Hoyer slings underneath them, inadequate use and maintenance of assistive devices such as Hoyer lifts, improper catheter care with drainage bags touching the floor, failure to consistently follow prescribed diets, and lapses in infection prevention and control practices including failure to wear PPE during high-contact care and inadequate disinfection of equipment.

The complaint involved an alleged resident-to-resident altercation on 7/19/24. The facility was aware of the incident on the day it occurred but did not notify administration until 7/22/24 and reported to the State Agency beyond the 24-hour requirement. The investigation could not identify which staff intervened. Education records for staff on duty during the incident were incomplete or missing.

The facility failed to thoroughly investigate an allegation of abuse between two residents and did not report the incident to the State Agency within the required 24-hour timeframe. Additionally, the facility could not provide proof of required staff education related to abuse reporting for staff working during the incident.

The facility was found deficient in multiple areas including failure to promote resident self-determination in meal choices, inadequate grievance resolution, incomplete background checks for employees, failure to provide timely transfer and bed hold notices to residents, unsafe use of assistive devices, inadequate fall assessments and interventions, improper respiratory care without physician orders, lack of monitoring for high-risk medications, improper garbage disposal, and an incomplete infection prevention and control program.

The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, incomplete background checks for staff, inadequate investigation of neglect allegations, employment of uncertified nursing assistants, failure to post nurse staffing daily, noncompliance with menu and food preparation standards, unsanitary food storage and preparation conditions, improper hand hygiene and food handling practices, failure to submit required payroll-based staffing data to CMS, and lack of an effective Legionella water management program.

The complaint involved an allegation of abuse by Certified Nursing Assistant (CNA)-F towards Resident R2. The facility did not conduct a thorough investigation, did not remove CNA-F from resident care during the investigation, and failed to update R2's care plan to reflect the resident's preference for assistance using two hands.

The facility failed to maintain current Background Information Disclosure forms for three staff members and did not thoroughly investigate an allegation of abuse involving one resident, allowing the alleged staff member to continue working during the investigation and failing to update the resident's care plan accordingly.

The complaint involved RN-E providing resident care and administering medication without an active license and destroying narcotic medication alone without a witness. The allegation of medication destruction was not investigated by the facility. RN-E's license was suspended with multiple restrictions, including prohibition from working in skilled nursing facilities or having access to controlled substances. The facility allowed RN-E to work and administer medication in violation of these restrictions.

The facility allowed RN-E to provide care and administer medication despite restrictions on RN-E's nursing license. RN-E administered medication to 40 residents in violation of license restrictions. Additionally, RN-E reportedly destroyed narcotic medication alone without a witness, violating facility policy. The facility did not investigate the allegation of medication destruction or misappropriation.

The complaint investigation involved allegations of physical abuse for Residents R8 and R1. R8 alleged abuse on 4/18/23 which was not reported to the State Agency. The facility investigated an allegation involving R1 but did not submit the required 5-day report timely. The Nursing Home Administrator confirmed delays and lack of awareness regarding reporting and investigation procedures.

The facility failed to timely report allegations of abuse for two residents to the State Agency and did not thoroughly investigate an allegation of abuse for one resident. The Nursing Home Administrator acknowledged delays in submitting required reports and lack of awareness of some abuse allegations.

The visit was complaint-related focusing on resident safety hazards, infection control deficiencies, COVID-19 testing and outbreak management, antibiotic stewardship, infection preventionist qualifications, and COVID-19 vaccination education and consent.

The facility failed to ensure resident safety by not providing accessible call lights to a resident, did not maintain an effective infection prevention and control program including inadequate COVID-19 outbreak investigation and testing, lacked a functional antibiotic stewardship program, did not have a qualified infection preventionist with required training, and failed to provide proper COVID-19 vaccination education and consent documentation for a resident.