Odd Fellow Home

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

Surveyor reviewed the facility's grievance file and noted R8 filed a grievance on 10/24/25 that indicated R8 was upset about PM/night shift cares. R8 indicated an unnamed CNA man-handled R8 and flopped my legs and they are still tender. R1 also stated the CNA was rude, just not kind when R8 told the CNA that R8 did not feel safe.

The grievance indicated R8 had a prolonged hospital stay due to a change in condition and did not recall the incident when R8 returned to the facility. R8 stated 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 R8's allegation of abuse.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Odd Fellow Home

1229 S Jackson St Green Bay, WI 54301

SUMMARY STATEMENT OF DEFICIENCIES

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) (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 R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis left ankle non-healing wound, epilepsy, peripheral vascular disease (PVD), depression, and osteoarthritis.

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 R2 had intact cognition.

The MDS assessment also indicated R2 required assistance with activities of daily living (ADLs). R2 was R2's own decision maker.On 11/18/25 at 9:06 AM Surveyor interviewed R2 who stated R2's medications were late most days, including R2's epilepsy medications. R2 indicated R2 had not yet received 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 R2's medications next. RN-C indicated R2 prefers to receive medication at 8:30 AM, however, RN-C was running late. RN-C verified 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 R2 has expressed concerns about receiving medications late.Surveyor reviewed R2's Medication Administration Record (MAR) which indicated R2's medications were administered late 8 times from 10/29/25 to 11/18/25.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. 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 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.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.

Facility ID: