Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Odebolt Specialty Care during CMS and state inspections, most recent first.
A resident experienced a fall with fractures to the heel and humerus, required hospital transfer and surgery, and returned needing a mechanical lift for transfers and increased assistance with turning and ADLs. Despite the major decline in function and care needs, the facility did not complete a Significant Change MDS, and the MDS Coordinator stated she did not recognize the ADL decline as meeting SCSA criteria.
Inaccurate MDS coding of medication use affected 3 residents. One resident with dementia and anxiety was coded as not receiving an antianxiety med even though MAR review showed Lorazepam was given twice daily. Another resident with CAD, HTN, and a humerus fracture was coded as receiving an anticoagulant on 2 MDS assessments even though the MAR and clinical record showed Rivaroxaban had ended months earlier. A third resident was also coded as receiving an anticoagulant despite no active anticoagulant orders in the record.
An LPN failed to maintain glove and hand hygiene practices during treatments for two residents. While providing a buttocks treatment for one resident and flushing a biliary tube for another, the LPN handled a walkie talkie and her gown/uniform with gloved hands, then continued the procedures without changing gloves or performing hand hygiene. The residents had multiple medical conditions, including diabetes, neurogenic bladder, chronic cholecystitis, and renal disease.
The facility inaccurately documented medication use for three residents in their MDS assessments. One resident was incorrectly recorded as receiving hypnotic medications, another as receiving anticoagulants, and a third as taking antianxiety medication, despite no corresponding physician's orders or administration records. Staff interviews confirmed these discrepancies.
The facility failed to provide comprehensive care plans for two residents regarding their high-risk medications. A resident with anxiety disorder and non-Alzheimer's dementia was receiving antidepressants, but their care plan lacked focus, goals, or interventions for these medications. Another resident with a history of stroke and intellectual disabilities was on antiplatelet medication, yet their care plan did not reflect this. Both a Registered Nurse and the Director of Nursing confirmed the expectation for accurate care plans, as per the facility's policy.
A facility failed to document vital signs and conduct a nursing assessment for a resident who returned from the ER after experiencing chest pain. Despite the resident's history of schizoaffective disorder and chronic lung disease, the facility did not follow its policy on managing acute condition changes, as confirmed by the DON.
A resident with severe cognitive impairment and high fall risk fell in the bathhouse when a CNA assisted them without a gait belt, contrary to facility policy. The resident, on anticoagulant medication, slipped on a wet floor, resulting in a bruise after hitting the whirlpool tub.
A resident with a suprapubic catheter was at risk for infections due to staff failing to follow enhanced barrier precautions (EBP) during catheter care. Two CNAs did not wear gowns as required, did not change gloves between tasks, and handled supplies without barriers. Despite being trained on EBP, the staff forgot to wear gowns, leading to a deficiency in infection prevention protocols.
A resident with cognitive impairments and a history of wandering fell down 13 concrete stairs in her wheelchair after kitchen staff left doors propped open and unsupervised. The resident sustained multiple injuries, including a laceration to her forehead and bruising. The facility's failure to secure doors and provide adequate supervision led to the accident.
Failure to Complete Significant Change MDS After Major Functional Decline
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Condition Assessment for one resident after a major decline in status. The resident’s quarterly MDS showed assistance needs for dressing, bed mobility, and transfers, but the clinical record later documented a fall with suspected injury, ambulance transfer to the hospital, and a subsequent hospital follow-up describing a right heel fracture and a left humerus fracture requiring surgery. After returning from the hospital, the resident required a mechanical lift for transfers and moderate assistance for turning, and later MDSs documented dependence for dressing and transfers and substantial/maximal assistance with bed mobility. Review of the MDS tracking page showed the resident was not set up for a Significant Change in Status MDS from October 2025 through March 2026. The MDS Coordinator stated she had not considered completing a Significant Change MDS for ADL declines and usually completed one only for hospice or an overall decline; she acknowledged a lack of knowledge or education regarding when one was required. The Corporate Nurse reported the facility had no policy related to Significant Change MDS and followed the RAI manual.
Inaccurate MDS Coding of Medication Use
Penalty
Summary
The facility failed to accurately assess residents by incorrectly coding medication use on the MDS for 3 of 5 residents reviewed. Resident #2 had diagnoses of non-Alzheimer's dementia and anxiety disorder, and the MDS indicated no antianxiety medication during the 7-day look-back period even though a physician order directed Lorazepam 0.25 mg twice daily for generalized anxiety disorder and the MAR showed the resident received Lorazepam twice a day during that period. The MDS Coordinator verified the antianxiety medication was not coded on the recent MDS. Resident #3 had diagnoses of coronary artery disease, hypertension, and a left humerus fracture, and two MDS assessments documented anticoagulation medication use during the 7-day look-back period. However, the MAR showed Rivaroxaban 10 mg daily had a start date of 10/16/25 and the last dose was given on 11/14/25, with no anticoagulant orders in the record from 11/15/25 through March 2026. The MDS Coordinator acknowledged Resident #3 was not taking an anticoagulant and that both MDS assessments were not coded correctly. Resident #1's MDS also documented anticoagulation medication use during the 7-day look-back period, but the clinical record showed no anticoagulant orders from 2/24/26 through 2/28/26.
Glove and Hand Hygiene Breaks During Resident Treatments
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed. Resident #28 had diagnoses including depression, diabetes mellitus, and neurogenic bladder, and was receiving Calmoseptine to the buttocks twice daily. During treatment, an LPN entered the room wearing a gown and gloves, held a medicine cup of cream, and while waiting for CNA pericare, answered a walkie talkie by moving the gown with one hand and returning the device to her uniform under the gown. She then continued the buttocks treatment with the same gloved hand that had touched the walkie talkie, gown, and uniform. The LPN later acknowledged she should have changed gloves and performed hand hygiene before completing the treatment. Resident #19 had diagnoses including chronic cholecystitis, diabetes mellitus, hyperlipidemia, and renal disease, with a biliary tube ordered to be flushed daily with normal saline. During the flush, an LPN entered the room wearing a gown and gloves, held a walkie talkie with her right hand, moved her gown with her left hand, and placed the walkie talkie on her uniform with her right hand. She then completed the biliary tube flush using the same gloves that had touched the walkie talkie, gown, and uniform, including removing the tube cap, cleansing the tube end with alcohol, attaching the syringe, flushing with normal saline, and cleansing the tube end again. The LPN acknowledged she should have changed gloves and performed hand hygiene before completing the flush.
Inaccurate Medication Documentation in MDS Assessments
Penalty
Summary
The facility failed to accurately assess and document the medication use of three residents during the observation period of the Minimum Data Set (MDS). For Resident #26, the MDS indicated the use of hypnotic medications for seven days, but the Electronic Healthcare Record (EHR) showed no physician's order for such medication. Similarly, Resident #27's MDS reported the use of anticoagulant medications for seven days, yet the EHR lacked any corresponding physician's order. Interviews with a Registered Nurse and the Director of Nursing confirmed that these residents were not on the medications as documented in the MDS. Additionally, Resident #24's MDS assessment inaccurately recorded the use of antianxiety medication over the last seven days, despite the Medication Administration Record showing no such medication was administered. The MDS Coordinator acknowledged the error in coding the MDS for Resident #24. The facility's policy on certifying the accuracy of resident assessments emphasizes that the information should reflect the resident's status during the observation period, which was not adhered to in these cases.
Deficiency in Comprehensive Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to provide comprehensive care plans for two residents regarding their high-risk medications. Resident #26, diagnosed with anxiety disorder and non-Alzheimer's dementia, was receiving antidepressant medications, including Trazadone and Escitalopram, daily. However, the care plan for Resident #26 did not include any focus, goals, or interventions related to these antidepressant medications. This oversight was confirmed by a Registered Nurse (RN) during an interview, who acknowledged that the care plan should have reflected the medication regimen. Similarly, Resident #27, who had diagnoses of non-traumatic subarachnoid hemorrhage, stroke, and moderate intellectual disabilities, was receiving antiplatelet medication. However, the care plan for Resident #27 did not include any focus, goals, or interventions for antiplatelet or anticoagulant medications. The RN confirmed that Resident #27 was not on an anticoagulant but was taking an antiplatelet medication, and the care plan should have reflected this. The Director of Nursing (DON) also confirmed the expectation for accurate care plans to be completed, aligning with the facility's policy for comprehensive, person-centered care plans.
Failure to Document and Assess Resident Post-ER Visit
Penalty
Summary
The facility failed to provide necessary assessment and interventions for a resident who returned from the emergency room (ER) after experiencing chest pain. The resident, who had intact cognition and a history of schizoaffective disorder, anxiety disorder, shortness of breath, and chronic lung disease, was sent to the ER due to chest pain and low blood pressure. Upon return from the ER, the facility did not document the resident's vital signs or conduct a nursing assessment, which was expected by the Director of Nursing (DON) for 72 hours post-return. The clinical record lacked documentation of the resident's condition upon return from the ER, and there was no follow-up focus nursing assessment related to the chest pain. The facility's policy on acute condition changes required that any acute changes be identified and managed properly, including reviewing hospitalization details to identify potential complications. However, this was not adhered to, as evidenced by the lack of documentation and assessment upon the resident's return.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severe cognitive impairment and a high risk for falls. The resident, who required partial to moderate assistance with daily activities and had a history of falls, was involved in an incident where a CNA assisted the resident out of a whirlpool chair without using a gait belt, resulting in a fall. The resident, who had multiple diagnoses including atrial fibrillation and non-Alzheimer's dementia, was on anticoagulant medication, which increased the risk of injury from falls. The incident report documented that the resident slipped on a wet floor in the bathhouse, hitting the right side of their back on the whirlpool tub, resulting in a bruise that could potentially develop into a hematoma. The facility's policy required the use of appropriate techniques and devices, such as gait belts, to ensure resident safety during transfers. However, the staff failed to adhere to these protocols, leading to the resident's fall and subsequent injury.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for a resident with a suprapubic catheter. The resident, who had moderately impaired cognition and required substantial assistance with daily activities, was at risk for infections due to the catheter. The care plan directed staff to perform catheter care every shift and follow enhanced barrier precautions (EBP) during high-contact care activities. However, during an observation, staff did not adhere to these precautions. During the observed catheter care, two certified nursing assistants (CNAs) did not wear gowns as required by the EBP policy. They washed their hands and wore gloves but failed to change gloves between dirty and clean tasks. The CNAs handled supplies without using a barrier and did not change gloves when moving from cleaning the resident's abdominal area to handling the catheter tubing and other tasks. The CNAs acknowledged their failure to wear gowns and reported they had been trained on EBP but forgot to put the gowns on during the procedure. The facility's policies on hand hygiene and EBP emphasize the importance of using gloves and gowns to prevent the spread of infections. The Director of Nursing (DON) confirmed the expectation for staff to use barriers with supplies, wear gowns during catheter care, and change gloves between tasks. Despite these policies, the staff's actions during the observed catheter care did not align with the facility's infection prevention protocols, leading to a deficiency in maintaining a sanitary environment for the resident.
Resident Falls Down Stairs Due to Unsecured Doors
Penalty
Summary
The facility failed to prevent an accident involving a resident with cognitive impairments who was known to wander. The incident occurred when kitchen staff left the main kitchen door propped open and unsupervised, allowing the resident to self-propel into the kitchen, through two more doors, and ultimately fall down 13 concrete stairs in her wheelchair. The resident was found at the bottom of the basement stairs by a kitchen staff member who heard her yelling for help. The resident sustained multiple injuries, including a laceration to her forehead and bruising to her face, neck, and arms. The resident had a history of cognitive impairments and was at risk for falls, as documented in her care plan. She was known to propel herself throughout the facility in her wheelchair independently and had a history of wandering. On the day of the incident, the resident was last seen at the nurse's station before she was found at the bottom of the stairs. Staff members were unaware of her whereabouts during the time she accessed the kitchen and fell down the stairs. The facility's investigation revealed that the kitchen door was left open during meal service, which was a common practice, and the basement door was also open. Staff interviews indicated that the resident was known to wander and required supervision, but the doors leading to non-resident areas were not secured, allowing her to access hazardous areas. The facility's failure to ensure that doors were closed and locked, and to provide adequate supervision, directly contributed to the resident's accident.
Removal Plan
- The facility audited all non-resident locked doors in the facility ensuring they were all locked and closed.
- The DON, Social Worker and Administrator began to call staff to educate them that all locked doors must remain shut and locked unless staff are present.
- Kitchen door will be audited upon completion of meal service daily for two weeks then weekly.
- Missing resident drills will be completed on varying shifts daily for two weeks then weekly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Odebolt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twilight Acres | 7.9 mi | ★★★★★ | 24 | 0 |
| Blackhawk Life Care Center | 9.6 mi | — | 3 | 1 |
| Park View Rehabilitation Center | 16 mi | ★★★★★ | 12 | 0 |
| Willow Dale Wellness Village | 18 mi | ★★★★★ | 2 | 0 |
| Denison Care Center | 19.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.