Deficiency Records for Odd Fellow Home
Updated as of May 01, 2024
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Deficiency Records for Odd Fellow Home
A list of the most recent deficiencies for Odd Fellow Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Odd Fellow Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-11 | 2023-10-02 | Y |
Respond appropriately to all alleged violations. | Health | 2023-09-11 | 2023-10-02 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-28 | 2023-07-24 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-28 | 2023-07-24 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-25 | 2023-05-19 | Y |
Respond appropriately to all alleged violations. | Health | 2023-04-25 | 2023-05-19 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-09 | 2023-04-14 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-08 | 2023-04-03 | N |
Provide and implement an infection prevention and control program. | Health | 2023-03-08 | 2023-04-03 | N |
Implement a program that monitors antibiotic use. | Health | 2023-03-08 | 2023-04-03 | N |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-08 | 2023-04-03 | N |
Perform COVID19 testing on residents and staff. | Health | 2023-03-08 | 2023-04-03 | N |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-08 | 2023-04-03 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-09 | 2023-04-03 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-09 | 2023-04-03 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-02 | 2022-02-28 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-02 | 2022-02-28 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-02 | 2022-02-28 | N |
Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-28 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-02-03 | 2022-02-25 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-03 | 2022-02-25 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-03 | 2022-02-25 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-03 | 2022-02-25 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-03 | 2022-02-25 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-03 | 2022-02-25 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-31 | 2021-05-14 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-03-31 | 2021-05-14 | N |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-03-31 | 2021-05-14 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-31 | 2021-05-14 | N |
Provide and implement an infection prevention and control program. | Health | 2021-03-31 | 2021-05-14 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-31 | 2021-05-07 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-30 | 2021-04-30 | N |
Develop a communication plan. | Fire Safety | 2021-03-30 | 2021-04-30 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-03-30 | 2021-04-30 | N |
Have an externally vented heating system. | Fire Safety | 2021-03-30 | 2021-04-30 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-12 | Not Fixed | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-12 | Not Fixed | Y |
Respond appropriately to all alleged violations. | Health | 2024-03-12 | Not Fixed | Y |
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-03-12 | Not Fixed | Y |
Post nurse staffing information every day. | Health | 2024-03-12 | Not Fixed | Y |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-03-12 | Not Fixed | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-12 | Not Fixed | Y |
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-03-12 | Not Fixed | Y |
Provide and implement an infection prevention and control program. | Health | 2024-03-12 | Not Fixed | Y |
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