Odd Fellow Home: Abuse Response Failures - WI

That is what federal inspectors found when they arrived at Odd Fellow Home, a nursing facility at 1229 South Jackson Street in Green Bay, on November 18, 2025.

The resident at the center of the abuse allegation, identified in inspection records only as R8, had been living at the facility with a serious list of diagnoses: congestive heart failure, respiratory failure, bipolar disorder, osteoarthritis, and a history of pathological falls. On a cognitive assessment completed November 4, 2025, R8 scored a 15 out of 15, the highest possible score, indicating fully intact cognition. R8 knew exactly what had happened and said so.

On October 24, 2025, R8 filed a formal grievance with the facility. The grievance described a PM or night shift encounter with a male CNA whose name R8 did not provide. The CNA, R8 wrote, man-handled R8 and flopped my legs and they are still tender. R8 also said the aide was rude, just not kind, and that when R8 told the CNA that R8 did not feel safe, the aide's response did nothing to reassure.

That grievance should have set off an immediate investigation. It did not.

R8 suffered a change in condition after filing the grievance and was hospitalized for a prolonged stay. When R8 returned to the facility, R8 no longer remembered the incident. By the time the investigation was formally closed on November 7, 2025, the only witness who could have described what the CNA did had lost the memory of it entirely.

The facility's own grievance policy required investigators to act immediately, identify the root cause of the allegation, interview other residents who might have been affected by the same aide, and collect witness statements from involved staff. None of that happened in any documented form. When inspectors reviewed the file on November 18, they found no staff education signatures showing that anyone had actually received training in response to the complaint. There was no further investigative documentation at all.

The nursing home administrator, identified in inspection records as NHA-A, confirmed as much during an interview at approximately 1:30 in the afternoon on the day of inspection. The facility, NHA-A said, did not have staff education signatures or further investigative documentation for R8's allegation of abuse. The grievance form itself was not even signed by NHA-A until November 17, 2025, more than three weeks after R8 filed it, and one day before federal inspectors walked through the door.

What the facility did produce was a single line of documentation showing that staff had been educated on taking their time with residents and to follow-up when needed. That education was signed off by the Assistant Director of Nursing on November 7, 2025. There were no names of who attended. No record of who the CNA was. No determination of whether the same aide continued working with R8 or with other residents in similar circumstances.

The man-handling allegation was not the only failure inspectors documented at Odd Fellow Home that day.

A second resident, identified as R1, had fallen at the facility. R1's care plan specified a clear transfer method: a sit-to-stand mechanical lift. Instead, according to inspection records, R1 was being transferred using a front-wheeled walker with the physical assistance of two staff members, a pivot transfer, which is a different technique entirely and one that R1's care plan did not authorize.

A licensed practical nurse, identified as LPN-E, had provided education to a certified nursing assistant, identified as CNA-F, about how to transfer R1. That education, the nursing home administrator confirmed to inspectors, did not accurately reflect the correct transfer technique listed in R1's care plan. The result was a witnessed fall.

NHA-A, reviewing the situation with inspectors on the morning of November 18, acknowledged that R1's care plan at the time of the fall had called for the sit-to-stand lift and that the training CNA-F received was wrong. NHA-A then said something that inspectors found worth recording: NHA-A did not feel the failure to follow the care plan was the primary cause of the fall.

The inspection report does not say what NHA-A believed the primary cause was.

R1's fall and R8's abuse allegation were addressed under the same federal deficiency, one that covers a nursing home's obligation to investigate and report allegations of abuse, neglect, and injury of unknown origin. The deficiency was cited at a level of minimal harm or potential for actual harm, the lowest tier of severity in the federal rating system. That classification reflects the regulatory judgment about what was documented, not necessarily what occurred.

What the inspection record does reflect is a facility where a cognitively sharp resident described being physically mishandled by a staff member, said she did not feel safe, and then lost her memory of the event during a hospitalization before anyone had interviewed a single witness or identified who the aide was. When she came back, she said she felt safe. The investigation was closed.

The grievance file did not contain the name of the CNA R8 described. The inspection report does not indicate the facility ever determined who that person was. There is no record that other residents on the PM or night shift were asked whether they had experienced anything similar.

The investigation was completed, at least on paper, on November 7. The administrator signed the grievance form on November 17. Federal inspectors arrived on November 18.

R8, her legs no longer tender and her memory of that night gone, told inspectors she felt safe at the facility.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Odd Fellow Home from 2025-11-18 including all violations, facility responses, and corrective action plans.

Additional Resources

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