Odebolt Specialty Care

In the surveyor’s words

From the most serious findings on record at Odebolt Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 11, 2024

  Based on observations, record review, staff, family and hospital staff interview the facility failed to prevent an accident from occurring for 1 of 3 residents (Resident #1) reviewed for wandering with cognitive impairments. The kitchen staff members left the main kitchen door propped open and unsupervised. Resident #1 self-propelled in to the kitchen, through the kitchen, through two more doors, which included the basement door where she fell down 13 concrete stairs in her wheelchair. A kitchen staff member heard someone yelling for help. She found Resident #1 at the bottom of the basement stairs with her wheelchair next to her. She alerted nursing staff. Staff provided first aide to the left side of her head until EMS arrived and transported her to the hospital. […]

• Actual harm, isolatedF684Jan 4, 2024

  Based on clinical record review, staff interview, and policy review the facility failed to assess or treat a resident's wound as order by the physician to promote healing for 1 of 5 residents reviewed (Resident #10) for wound care. Resident #10 admitted to the facility on [DATE] following a stay in the hospital. On admission, she had a wound to her right lower leg that required treatment of a wound vacuum (vac) to promote healing. Since the time of her admission, the facility only assessed her right lower leg wound on the day of admission and the day of her discharge, 19 days later. The facility then only assessed the left leg wound on day after admission and the date of discharge, 18 days later. […]

• Actual harm, isolatedF695Jan 4, 2024

  Based on clinical record review, facility policy review, staff, resident, and family interviews, the facility failed to provide adequate oxygen therapy for 1 of 1 resident reviewed (Resident #9). Due to a diagnosis of congestive heart failure and a recent hospital stay that included Resident #9 requiring the use of a ventilator, she required the use of supplemental oxygen. The staff failed to monitor Resident #9 vital signs and the oxygen tank to ensure she received the proper amount of oxygen. When the staff went to help Resident #9 to lunch, they found her unresponsive with an oxygen saturation of 45% and an empty oxygen tank. While at the hospital, the staff found Resident #9 had anoxic brain injury (a type of brain injury caused by the deprivation of oxygen). […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2024

  Based on observations, staff interviews, and facility policy reviews the facility failed to store and prepare food sanitary conditions. The facility identified a census of 30 residents. Findings included: The initial kitchen walkthrough on 3/11/24 at 9:40 AM revealed the following: 1. The bottom of the single door refrigerator, double door refrigerator, and double door refrigerator contained an accumulation of food debris and dried liquid. 2. The floor in the kitchen and dishwashing area contained a variety of scattered food debris and dried liquid. Areas of the kitchen floor found to be slippery or sticky. 3. Open shelving beneath the hot food and preparation table contained food debris and dried liquid. 4. Crusty, flaky lime like substance found in the following places: a. […]

• No harm, potential for more than minimal, patternF710Jan 4, 2024

  Based on interview record review and policy review, the facility failed to include signed physician's orders in residents clinical record for 5 of 5 residents reviewed (Residents #2, #9, #10, #14 and #15). Findings include: A review of the files for Residents #2, #9, #10, #14 and #15 revealed their clinical records lacked signed Physician Order Sheets (POS). On 1/2/24 at 8:30 AM the Director of Nursing (DON) said she would look for the POS documents for the 5 residents. On 1/3/24 at 7:00 AM the Administrator didn ' t know about the documents and said she would look into it. On 1/3/24 at 10:50 AM Staff K, Regional Director, said they were still trying to find the POS for the 5 residents. […]