Odd Fellow-Rebekah Home

In the surveyor’s words

From the most serious findings on record at Odd Fellow-Rebekah Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 18, 2022

  Based on interview and record review the facility failed to provide supervision for one of three residents (R2) reviewed for falls in the sample of three by leaving R2 on the toilet unsupervised. This failure resulted in R2 falling and received a life-threatening head injury, large subdural hematoma, which caused R2's death. This failure resulted in an Immediately Jeopardy. The Immediate Jeopardy began on [DATE] when (R2) was found on R2's bed after being left unsupervised on the toilet. The Immediate Jeopardy was identified on [DATE]. V1 Administrator, was notified of the Immediate Jeopardy on [DATE] at 11:55 AM. […]

• Immediate jeopardy, isolatedF686Aug 16, 2021

  These failures require more than one deficient practice statement. A. Based on interview, and record review, the facility failed to identify, observe, assess, notify and implement targeted interventions to prevent the development and/ or worsening of an unstageable pressure ulcer for a resident. These failures include lack of skin assessment checks, bathing, repositioning assists, incontinence care assists, transfer assists for a resident who required extensive assistance, and hydration. This failure affects one R1 of three residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF600Jun 16, 2026

  Based on observation, interview, and record review the facility failed to ensure one resident (R1) was free from physical abuse from another resident (R2). This failure caused R1 to sustain a nasal fracture, a facial laceration requiring sutures to close, and bilateral hematomas to her eyes.Findings Include: R2's Care Plan, updated 6/16/26, includes the following diagnoses: Dementia, Hypertension (HTN), Hyperlipidemia, Pseudobulbar Affect, Seizure Disorder, and Aneurysm of the Aortic Arch.The Care Plan includes a problem initiated on 1/14/25 documenting that R2 has physical behavioral symptoms, including pulling others' hair, shoving or hitting others, and throwing items at others. The Care Plan also documents verbal behavioral symptoms, including yelling and growling at others. […]

• Actual harm, isolatedF689Apr 24, 2026

  Based on observation, interview and record review the facility failed to implement a baseline careplan for one (R2) resident, failed to implement fall interventions for three (R2, R3, R4) residents, failed to ensure the safety of one (R3) resident and failed to complete comprehensive fall investigations for three (R2, R3, R4) residents out of three residents reviewed for Accidents in a sample list of ten residents. R3 obtained five sutures to her forehead and a Subdural Hematoma due to an unwitnessed fall at the facility. R3 was transported to the emergency room to undergo diagnostic testing, laboratory work and full assessments from hospital staff. R3 experienced pain due to falling off her bed that was in high position. […]

• Actual harm, isolatedF600Feb 20, 2026

  Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two (R4, R6) of three residents reviewed for abuse in the sample list of 7. This failure resulted in R4 sustaining a fracture to her right wrist.Findings include:R4's health status note dated 12/27/25 documents that R4 allegedly had a physical altercation with another resident that resulted in R4 falling to the ground and sent to the emergency room for evaluation.R4's event note dated 12/28/25 documents that R4 was pushed by another resident (R6).R4's progress notes dated 12/28/25 documents R4 returned to the facility form the emergency room with a soft cast to her right hand due to a fracture.On 2/19/26 at 11:50… […]