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 |
| 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 |
