ODD FELLOW AND REBEKAH NURSING HOME

Nursing Home Inspector

2300 SOUTH OAK GROVE RD
ENNIS, TX 75119
Ellis County
Phone: 972-875-8643
Provider Number: 675150
Last Inspection: 05/26/2017

About the Nursing Home

Number of Beds: 108
Number of Residents: 62
Beds Available: 46
Percent Occupancy: 57%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Other
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

23

Facility
13

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

23

2017
23

2016
30

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/26/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Widespread : Minimal 5 6/14/2017
 
Failed To: Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Widespread : Minimal 5 6/14/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/14/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 6/14/2017
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 6/14/2017
 

6/16/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Widespread : Minimal 5 7/13/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 7/13/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/20/2016
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Widespread : Minimal 5 7/18/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Widespread : Minimal 5 7/18/2016
 

6/26/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. Pattern : Minimal 4 7/1/2015
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Widespread : Potential 4 8/1/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 7/1/2015
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Widespread : Minimal 5 8/1/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 8/1/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 8/1/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 8/1/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

12/17/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Minimal 5 2/8/2016
 

4/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Immediate 6 5/8/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Immediate 6 5/8/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Immediate 6 5/8/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Immediate 6 5/8/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Immediate 6 5/8/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 62 72.56 75.11
Registered Nurses 0.44 0.59 0.59
Licensed Practical / Vocational Nurses 1.09 0.83 0.94
Certified Nursing Assistants 2.43 2.32 2.20
Total Staff Hours 3.97 3.74 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 3 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 89 90 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 71 84 92
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 3 6 3
of long-stay residents who lose too much weight 4 5 5
of long-stay residents who received an antianxiety or hypnotic medication 15 26 26
of long-stay residents who received an antipsychotic medication 8 16 17
of long-stay residents who self-report moderate to severe pain 7 4 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 23 20
of long-stay residents whose need for help with daily activities has increased 19 22 18
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 37 43 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 28 71 77
of short-stay residents who had an outpatient emergency department visit 26 16 13
of short-stay residents who made improvements in function 70 63 59
of short-stay residents who newly received an antipsychotic medication 9 3 2
of short-stay residents who self-report moderate to severe pain 13 11 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 57 64 74
of short-stay residents who were rehospitalized after a nursing home admission 22 23 23
of short-stay residents who were successfully discharged to the community 51 49 46
of short-stay residents with pressure ulcers that are new or worsened 0 0 0