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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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-03-12 | 2024-04-12 | 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 | 2024-04-12 | Y |
| Post nurse staffing information every day. | Health | 2024-03-12 | 2024-04-12 | 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 | 2024-04-12 | 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 | 2024-04-12 | 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 | 2024-04-12 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-12 | 2024-04-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-12 | 2024-04-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-03-12 | 2024-04-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-12 | 2024-04-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-12 | 2024-04-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-12 | 2024-04-12 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-12 | 2024-04-12 | 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 | 2024-04-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-12 | 2024-04-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-12 | 2024-04-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| 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 |
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