Odd Fellow Home: Pharmacy Service Failures - WI
That's what federal inspectors found when they visited Odd Fellow Home at 1229 S. Jackson Street on November 18, 2025.
The resident, identified in inspection records as R8, filed her grievance on October 24. She described a PM or night shift CNA who handled her roughly during care. "Man-handled R8 and flopped my legs and they are still tender," the grievance stated, in her own words. When R8 told the CNA she did not feel safe, she said the aide was "rude, just not kind."
R8 had intact cognition. Her most recent cognitive assessment, completed November 4, gave her a perfect score of 15 out of 15 on the Brief Interview for Mental Status, the standardized tool nursing homes use to measure a resident's ability to recall and communicate accurately. She knew what happened to her. She reported it.
Then she had a change in condition serious enough to require a prolonged hospital stay. When she came back, she no longer remembered the incident. By the time the facility closed the investigation on November 7, R8 told staff she felt safe and didn't recall what she had described two weeks earlier.
The facility treated that as a resolution.
The investigation was signed off by the Assistant Director of Nursing on November 7. The nursing home administrator signed the grievance form on November 17, the day before inspectors arrived. In the space where a thorough investigation should have been documented, there was almost nothing. No witness statements from staff who worked that shift. No interviews with other residents who might have had similar experiences with the same aide. No root cause finding. No identification of which CNA R8 had been describing.
When the inspector sat down with the nursing home administrator, identified as NHA-A, at approximately 1:30 in the afternoon on November 18, the administrator confirmed it directly. The facility did not have staff education signatures or further investigative documentation for R8's allegation.
The aide was never identified by name in the record. The shift was narrowed to PM or nights. That was the extent of it.
The facility's own policy required something different. Investigate abuse allegations immediately. Identify the root cause. Interview other potentially affected residents. Obtain witness statements from involved staff. None of those steps were documented as completed. Staff were educated, the grievance form noted, on "taking their time with residents and to follow-up when needed." The education was signed by the assistant director of nursing. But when inspectors asked for the signatures showing which staff had received that education, they didn't exist.
R8's grievance described a specific person doing a specific thing during a specific shift. The response was a general lesson about being patient, signed by a supervisor, with no record that the staff member who flopped her legs ever sat in the room.
The second finding from the same inspection day involved a different resident and a different kind of failure, one that was witnessed in real time.
R1, whose full diagnoses are not detailed in the inspection record, had a care plan that specified how she was to be moved. The plan called for a sit-to-stand lift, a mechanical device that supports a resident's weight during transfers and reduces the risk of falls. On the day of R1's fall, she was moved using a front-wheeled walker and the physical assistance of two staff members instead.
That's a pivot transfer. It's a different technique, requiring different weight-bearing ability and a different kind of coordination between the resident and the people helping her. R1's care plan said she needed the lift. She got the walker.
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 did not accurately describe the technique R1's care plan required. The administrator confirmed this to the inspector during an interview at 11:49 in the morning. LPN-E taught the wrong method. CNA-F learned the wrong method. R1 fell.
The administrator then said something worth sitting with. NHA-A did not feel that failing to follow the care plan was the primary cause of R1's fall.
The care plan existed for a reason. It specified a mechanical lift for a reason. A nurse taught a technique that contradicted it. The resident fell. The administrator's position, stated to a federal inspector, was that the care plan deviation was not primarily responsible.
What the primary cause was, in the administrator's view, is not recorded in the inspection narrative.
Inspectors classified both deficiencies under the same federal tag, F610, which covers the requirement to report and investigate allegations of abuse, neglect, and other mistreatment. The level of harm was assessed as minimal harm or potential for actual harm, affecting a few residents. That's not the most severe category in the federal rating system, but it is a finding of a failed investigation into a reported abuse allegation, and a finding that a resident fell after being transferred in a way her own care plan said not to use.
The inspection was complaint-driven, meaning someone, a resident, a family member, or a staff member, contacted authorities before inspectors arrived.
R8 came back from the hospital and said she felt safe. That's in the record. It's also in the record that by the time she said it, she no longer remembered what she had reported. The facility closed the investigation on the strength of a statement made by a resident who had forgotten the incident she had filed a grievance about.
The CNA she described, the one who was rude when she said she felt unsafe, the one who flopped her legs and left them tender, was never named, never interviewed on record, and never confirmed to have received any education about what she reported.
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
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Odd Fellow Home in Green Bay, WI was cited for violations during a health inspection on November 18, 2025.
That's what federal inspectors found when they visited Odd Fellow Home at 1229 S.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.