Odd Fellow Home

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

intact cognition. On 11/18/25, Surveyor reviewed a grievance provided by NHA-A that indicated Resident R8 reported to staff on 10/24/25 that Resident R8 was upset about cares during the PM/night (NOC) shift. Resident R8 indicated a CNA man-handled Resident R8 and flopped my legs and they are still tender. Resident R8 also indicated the CNA was rude, just not kind after the CNA rolled Resident R8 in bed and Resident R8 stated Resident R8 felt unsafe. The grievance findings indicated Resident R8 had a prolonged hospital stay due to a change in condition and did not recall the incident when Resident R8 returned to the facility. Resident R8 stated Resident R8 felt safe at the facility upon return. Staff were educated on taking time with residents and to follow-up when needed. The education was signed by Assistant Director of Nursing (ADON)-D on 11/7/25. The grievance form was signed by NHA-A on 11/17/25.On 11/18/25 at approximately 1:30 PM, Surveyor interviewed NHA-A who verified the allegation of abuse should have been reported to the SA.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Odd Fellow Home

1229 S Jackson St Green Bay, WI 54301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

transferred via pivot transfer with a front-wheeled walker with the assistance of 2 staff. On 11/18/25 at 11:49 AM, Surveyor interviewed NHA-A who verified Resident R1's care plan at the time of the fall indicated Resident R1 should have been transferred with a sit-to-stand lift and that LPN-E's education to CNA-F did not accurately reflect

the correct transfer technique for Resident R1. NHA-A indicated NHA-A did not feel lack of following the care plan was the primary cause of Resident R1's witnessed fall. 2. On 11/18/25, Surveyor reviewed Resident R8's medical record. Resident R8 was admitted to the facility on [DATE REDACTED] and had diagnoses including congestive heart failure (CHF), respiratory failure, bipolar disorder disorder, falls, and osteoarthritis with pathological falls. Resident R8's MDS assessment, dated 11/4/25, had a BIMS score of 15 out of 15 which indicated Resident R8 had intact cognition.

Surveyor reviewed the facility's grievance file and noted Resident R8 filed a grievance on 10/24/25 that indicated Resident R8 was upset about PM/night shift cares. Resident R8 indicated an unnamed CNA man-handled Resident R8 and flopped my legs and they are still tender. Resident R1 also stated the CNA was rude, just not kind when Resident R8 told the CNA that Resident R8 did not feel safe. The grievance indicated Resident R8 had a prolonged hospital stay due to a change in condition and did not recall the incident when Resident R8 returned to the facility. Resident R8 stated Resident R8 felt safe in the facility and the investigation was completed on 11/7/25. Staff were educated on taking their time with residents and to follow-up when needed. The education was signed by Assistant Director of Nursing (ADON)-D on 11/7/25.

The grievance form was signed by NHA-A on 11/17/25. A thorough investigation was not completed in accordance with the facility's policy which indicates to investigate abuse allegations immediately, identify

the root cause, interview other potentially affected residents, and obtain witness statements from involved staff. On 11/18/25 at approximately 1:30 PM, NHA-A indicated the facility did not have staff education signatures or further investigative documentation for Resident R8's allegation of abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Odd Fellow Home

1229 S Jackson St Green Bay, WI 54301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, staff and resident interview, and record review, the facility did not ensure administration of medication in accordance with physician orders for 1 resident (R) (Resident R2) of 1 sampled residentR2's AM and PM medications were administered late on multiple occasions. Findings include:The facility's Administration of Medication policy, dated April 2019, indicates: .Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). On 11/18/25, Surveyor reviewed Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED] and had diagnoses including osteomyelitis left ankle non-healing wound, epilepsy, peripheral vascular disease (PVD), depression, and osteoarthritis. Resident R2's most recent Minimum Data Set (MDS) assessment, dated 11/11/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident R2 had intact cognition. The MDS assessment also indicated Resident R2 required assistance with activities of daily living (ADLs). Resident R2 was Resident R2's own decision maker.On 11/18/25 at 9:06 AM Surveyor interviewed Resident R2 who stated Resident R2's medications were late most days, including Resident R2's epilepsy medications. Resident R2 indicated Resident R2 had not yet received Resident R2's AM medications. On 11/18/25 at 9:26 AM, Surveyor observed Registered Nurse (RN)-C administer medications to residents. Surveyor interviewed RN-C who indicated RN-C was running late with medication pass and was going to administer Resident R2's medications next. RN-C indicated Resident R2 prefers to receive medication at 8:30 AM, however, RN-C was running late. RN-C verified Resident R2's medications were scheduled for 8:00 AM and indicated staff can administer medication up to an hour before or after the scheduled time. RN-C confirmed that Resident R2 has expressed concerns about receiving medications late.Surveyor reviewed Resident R2's Medication Administration Record (MAR) which indicated Resident R2's medications were administered late 8 times from 10/29/25 to 11/18/25.Resident R2 was scheduled to receive the following medications at 8:00 AM: multivitamin 1 tablet; aspirin 81 mg 1 tablet; vitamin D 25 micrograms (mcg) 2 tablets; probiotic 1 capsule twice daily; levetiracetam (an antiepileptic medication) 1,000 mg 2.5 tablets twice daily; amlodipine 5 mg 1 tablet daily, gabapentin 400 mg 3 capsules 3 times daily; clopidogrel 75 mg 1 tablet daily; and meropenem intravenous solution reconstituted 2 grams (gm) 1 dose intravenously (IV) every 8 hours. Resident R2's MAR indicated the medications were administered late

on the following dates: ~ 10/31/25 - administered at 9:30 AM~ 11/1/25 - administered at 10:03 AM~ 11/6/25 - administered at 10:06 AM~ 11/11/25 - administered at 9:26 AM~ 11/14/25 - administered at 9:10 AM~ 11/15/25 - administered at 9:11 AM~ 11/18/25 - administered at 9:26 AM Resident R2 was scheduled to receive the following medications at 8:00 PM: mirtazapine 15 mg 1 tablet at bedtime; levetiracetam 1,000 mg 2.5 tablets twice daily; probiotic 1 capsule twice daily; gabpentin 400 mg 3 capsules 3 times daily; atorvastatin 20 mg 1 tablet at bedtime; and topiramate 25 mg 1 tablet at bedtime.Resident R2's MAR indicated the medications were administered late on the following date:~ 10/29/25 - administered at 11:04 PMOn 11/18/25 at 11:25 AM, Surveyor interviewed Nusing Home Administrator (NHA)-A who indicated nurses have an hour before or after the prescribed time to administer medications to residents.

Event ID:

Facility ID:

If continuation sheet