Deficiency Records for Odd Fellow Home
Updated as of March 01, 2022
This is not the most recent data for Odd Fellow Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-28 | 2021-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-28 | 2021-05-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-28 | 2021-05-24 | Y |
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-09-15 | 2020-10-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-09-15 | 2020-10-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-09-15 | 2020-10-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-26 | 2019-10-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-17 | 2019-10-07 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-19 | 2019-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-17 | 2019-08-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-19 | 2019-08-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-19 | 2019-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-19 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-17 | 2019-08-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-17 | 2019-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-17 | 2019-08-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-17 | 2019-08-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-19 | 2019-08-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-19 | 2019-07-31 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-07-19 | 2019-07-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-07-19 | 2019-07-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-19 | 2019-07-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-19 | 2019-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-19 | 2019-07-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-19 | 2019-07-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-19 | 2019-07-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-04 | 2019-06-26 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-06-04 | 2019-06-26 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-05-21 | 2019-06-14 | Y |
| 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 | 2019-04-15 | 2019-05-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-15 | 2019-05-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-04-15 | 2019-05-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-15 | 2019-05-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-19 | 2018-10-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-19 | 2018-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-19 | 2018-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-19 | 2018-10-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-09-17 | 2018-10-09 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-09-17 | 2018-10-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-17 | 2018-09-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-17 | 2018-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-17 | 2018-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-17 | 2018-09-18 | N |
