Inspection Reports for
Odebolt Specialty Care

The facility failed to accurately document medication use in resident assessments, provide comprehensive care plans for high-risk medications, complete necessary nursing assessments after hospital return, ensure adequate supervision to prevent accidents, and maintain proper infection prevention and control practices.

The facility failed to accurately represent residents' medication use in Minimum Data Set (MDS) assessments for 3 residents, failed to provide comprehensive care plans related to high-risk medications for 2 residents, failed to maintain quality of care for 1 resident including proper assessment after ER visits, failed to provide adequate supervision to prevent accidents for 1 resident, and failed to maintain infection prevention and control for 1 resident with catheter care.

Complaints #121889-C and facility reported incident #121955-I were substantiated. The incident involved Resident #1 falling down 13 basement stairs after wandering through an unsupervised kitchen door left propped open.

The facility failed to prevent an accident for a cognitively impaired resident who self-propelled in her wheelchair through an unsupervised, propped-open kitchen door and fell down 13 basement stairs, sustaining multiple injuries. The facility implemented corrective actions including door audits and staff education.

The investigation was triggered by a complaint regarding the facility's failure to prevent Resident #1, who had severe cognitive impairments, from wandering unsupervised through multiple doors leading to a basement stairwell where she fell. The incident occurred on July 2, 2024. The facility reported immediate jeopardy which was removed after corrective actions were implemented on the same day. The resident was hospitalized with facial lacerations, bruising, and a closed head injury. Staff interviews revealed doors were left open during meal service and staff failed to maintain supervision.

The facility failed to prevent an accident for Resident #1 who fell down 13 concrete stairs in her wheelchair after wandering through unlocked doors. Staff failed to keep doors locked and supervise the resident adequately, resulting in immediate jeopardy to resident health and safety. The resident sustained significant injuries and was hospitalized.

The facility was found deficient in completing accurate resident assessments, timely skin assessments and treatment for diabetic ulcers, maintaining sanitary food storage and preparation areas, and proper infection prevention practices related to catheter drainage bags.

Complaint #119308-C was substantiated.

The facility was found not in compliance with multiple requirements including accuracy of resident assessments, quality of care related to skin assessments and diabetic ulcers, food procurement and sanitary preparation, and infection prevention and control practices related to catheter drainage bags.

The facility was found deficient in completing accurate resident assessments, providing appropriate treatment for a diabetic ulcer, maintaining sanitary food storage and preparation areas, and implementing proper infection prevention practices related to catheter drainage bags.

The complaint investigation included intakes #112960-C, #113290-C, #113338-I, #113357-C, and #1176474-C. Complaints #112960-C, #113290-C, #113357-C, and #1176474-C were substantiated. Facility reported incident #113338-I was substantiated.

The facility was found non-compliant with multiple federal regulations including failure to treat residents with dignity and respect, failure to notify physicians timely about resident discharges, inadequate wound care, inadequate supervision leading to resident elopement, failure to provide adequate oxygen therapy, and lack of signed physician orders in clinical records.

The complaint investigation included allegations of disrespectful treatment of residents, failure to notify physicians about discharges, inadequate wound care, inadequate supervision leading to elopement, failure to provide adequate oxygen therapy, and missing signed physician orders.

The facility failed to treat residents with dignity and respect, failed to notify physicians timely about resident discharges, failed to provide adequate wound care and oxygen therapy, failed to provide adequate supervision to prevent elopement, and lacked signed physician orders in clinical records for multiple residents.

Complaint #107965 was investigated and found to be unsubstantiated.

The facility failed to notify the provider of medications not received by Resident #14 after hospital discharge and failed to administer four different medications for six consecutive days. The facility also failed to follow physicians' orders for medication administration related to blood pressure parameters for Resident #14. Additional findings included failure to coordinate PASARR assessments and failure to provide accurate dialysis assessments for Resident #14.

The complaint investigation substantiated failures in medication administration, PASRR referral and resubmission, and dialysis care for specific residents, including Resident #14, #15, and #23.

The facility failed to clarify inconsistent discharge medication orders and failed to administer four medications to Resident #14 for six consecutive days. The facility also failed to refer residents for PASRR Level II evaluations as required and failed to provide accurate pre and post dialysis assessments for Resident #14. Additionally, staff failed to follow blood pressure parameters when administering medication for hypotension.

Complaints #100313-C and #107050-C were not substantiated. Complaint #107422-C was substantiated. Facility reported incident #105515-I was substantiated. Facility reported incident #107178-I was not substantiated.

The facility was found to have insufficient nursing staff to meet resident needs, resulting in delayed call light responses and inadequate care. Medication administration deficiencies were also identified, including failure to accurately reconcile controlled substances and narcotic counts. Several residents reported concerns about staffing shortages and care delays.

The facility was found deficient in several areas including comprehensive resident assessments, development and implementation of comprehensive care plans, food procurement and sanitation, quality assurance and performance improvement meetings, and infection prevention and control. Deficiencies were corrected by the Regional Director of Clinical Services and other staff by specified correction dates.

The facility failed to maintain a sanitary environment to prevent pathogen transmission for 5 of 24 residents in isolation and lacked current infection control policies aligned with national standards. Observations included lack of signage, PPE, and proper handling of isolation protocols.