Inspection·May 14, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm R6's MDS assessment dated [DATE] documented no BIMS assessment was conducted due to the resident is rarely/never understood. R6's Bowel and Bladder assessment dated [DATE] documented: 1. a. void appropriately without incontinence: with 'never' marked. Residents Affected - Some On 05/05/25 at 12:34PM, R6 was sitting in the dining room in her wheelchair with her pants wet from just below her waist to almost her knees. There was urine under her wheelchair causing a puddle over 12 inches across and over six inches wide. On 05/05/25 between 12:34PM and 1:33PM, R6 sat in the dining room eating her lunch while wet with a puddle of urine underneath her with several staff walking by her, not attending to her incontinence or cleaning the puddle of urine. On 05/05/25 at 1:33PM, V17 (Certified Nurse Aide/CNA) put a towel over the urine, went and acquired gloves, cleaned the urine and removed R6 and the towel from the dining room. On 05/05/25 at 1:36PM, V17 took R6 to get changed. On 05/08/25 at 2:00PM, V3 (ADON) stated, any resident that has an accident in the dining room, she would expect staff to try to take the resident to get changed and the urine on the floor should have been discreetly cleaned up. R6 should not have been left wet for an hour in the dining room, she should have been cleaned up and the urine discretely cleaned up. 4. R22's admission Record dated 05/08/25 documented an admission date of 08/08/24 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, aphasia following other cerebrovascular disease and type 2 diabetes mellitus. R22's MDS assessment dated [DATE] documented a BIMS score of 04, indicating severe cognitive impariment. R22's MDS also documented she requires supervision or touching assistance with eating. R22's Care Plan documented a focus area of: Altered Nutrition and hydration (Risk) r/t (related to) GI (gastrointestinal) disturbance. Another focus area documents: Self-Care deficit as evidenced by needs assistance with ADL'S (Activities of Daily Living). Interventions include in part: Eating -supervision to one-person physical assist required. On 05/06/25 at 12:25PM, during lunch meal, V12 (Certified Nurse Assistant) was standing up and giving several bites of food to R22, then walked over to the door to go punch in the code on the keypad to assist a resident in from smoking. V12 then went back to assisting R22 to eat while standing up. On 05/06/25 at 12:36PM, V12 was still standing up assisting R22 to eat and again walked over to open the door for several residents that were outside smoking. V12 returned to R22 and resumed assisting R22 to eat, again while standing. On 05/06/25 at 12:45PM, V12 had continued to stand and assist R22 to eat. V12 went to the door again to help residents come in from smoking outside. V12 returned and continued to stand while assisting R22 to eat. On 05/08/25 at 9:14AM, V12 stated that management at the facility told her that she needs to not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sit down in the resident's chair because they are hard, and she is currently on work compensation for a back injury. V12 stated that she doesn't remember who told her that she couldn't sit in the resident chairs. V12 stated that she normally always stands up when assisting resident with eating. V12 stated that she was going over to open the door because that is what she normally does to let the smokers in. V12 also stated that she stands up when assisting residents with eating so if another resident falls in the dining room, she can get to them quicker. On 05/08/25 at 9:44AM, V2 (Director of Nursing/DON/Regional Nurse) stated that he was not aware of V12 having to stand to assist residents with eating. V2 stated that he has seen V12 sit down in other chairs. On 05/08/25 at 10:07AM, V2 (DON/Regional Nurse) stated that V12 doesn't have any sitting restrictions and should be able to sit and assist residents with eating. The facility policy titled Quality of Life-Dignity with a revised date of 10/09 documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to provide a clean and homelike environment for 2 (R49 and R54) of 4 residents reviewed for environment in a sample of 46. Residents Affected - Few Findings include: On 5/6/25 at 9:20AM, a feces soiled bedpan was seen sitting in the bathtub of R54 and R49's shared bathroom. On 5/6/25 9:20AM, R54 was alert and oriented and stated he knew the staff stored his bedpan in the bathtub, but did not know they were not cleaning it before storing it. On 5/6/25 at 2:49PM, the same soiled bedpan was noted to be in R54 and R49's shared bathtub. On 5/7/25 at 8:15AM, the same soiled bedpan was noted to be sitting in R54's and R49's bathtub. On 5/7/25 at 11:30AM, the same soiled bedpan was noted to still be sitting in R54's and R49's bathtub. On 5/7/2025 at 11:30AM, R49 was alert and oriented and stated he was not aware of a soiled bed pan being left in the bathtub in his bathroom. R49 said he was upset by the soiled bedpan causing a foul odor in his room and asked the staff to remove it. On 5/7/25 at 11:45AM, V9 (Housekeeper) said a soiled bed pan should not be left in the resident's bathroom. V9 removed the soiled bed pan from R49 and R54's bathtub. On 5/8/25 at 12:15PM, V2 (Director of Nursing/DON) stated staff should not be leaving feces soiled bedpans in resident's bathrooms. The Facility policy titled Bedpan or Urinal Procedure (non-dated) documented after assisting resident with the bedpan, (staff are to) clean the bedpan, wipe dry and store the bedpan per facility policy. Do not leave (the bedpan) in the bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that services were provided within the professional scope of practice when nursing staff administered and documented multiple medications late to 3 (R8, R23, and R37) of 5 residents reviewed for medication administration in a sample of 46. Residents Affected - Few Findings include: 1. R23's admission Record documented an admission date of 09/29/2022 and included diagnoses of type 2 diabetes mellitus with diabetic neuropathy and depression. R23's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R23 is cognitively intact. R23's Medication Admin Audit Report documents the following physician's orders: Desmopressin Acetate Tablet 0.1 MG (milligram), Give 1 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:32pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (Licensed Practical Nurse/LPN). Desmopressin Acetate Tablet 0.2 MG, Give 1 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Metformin HCI Tablet 500 MG, Give 2 tablet by mouth two times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Asmanex (120 Metered Doses) Inhalation Aerosol Powder Breath Activated 220 MCG/ACT (Mometasone Furoate (Inhalation)) 2 puff inhale orally two times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 8:32pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Melatonin Oral Tablet 1 MG (Melatonin), Give 1 mg by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Artificial Tears Ophthalmic Solution 1% (Carboxymethylcellulose Sodium (Ophth)) Instill 1 drop in both eyes at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:31pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Gabapentin Capsule 100 MG Give 2 capsule by mouth three times a day, with a schedule date of 05/05/25 at 9pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). On 05/06/25 at 09:06am, R23 stated it depends on which nurse is working as to whether he gets his medications on time. R23 stated it was early morning before he received the meds he should have received before bedtime last night. R23 stated it always happens with agency nurses, especially V13 (LPN). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm 2. R8's admission Record documented an admission date of 07/11/24 and included diagnoses of type 2 diabetes mellitus without complications and chronic obstructive pulmonary disease. R8's MDS assessment dated [DATE] documented a BIMS score of 9, indicating that R8 has moderate cognitive impairment. Residents Affected - Few R8's Medication Admin Audit Report documents the following physician's orders: Tresiba FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML (milliliters) (Insulin Degludec) Inject 66 unit subcutaneously two times a day, with a schedule date of 05/04/25 at 8pm, with an administration time of 05/05/25 at 12:13am, and a documentation time of 12:19am on 05/05/25 by V24 (Registered Nurse/RN). This same medication was scheduled on 05/05/25 at 8pm with an administration date of 05/05/25 at 7:43pm, and a documentation time of 11:44pm by V13 (LPN). Doxycycline Hyclate Oral Capsule 100 MG (Doxycycline Hyclate), Give 100 mg by mouth every 12 hours, with a schedule date of 05/04/25 at 9pm, an administration time of 05/05/25 at 12:19am, and a documentation time of 12:19am on 05/05/25 by V24 (Registered Nurse-RN). This same medication was scheduled at 9pm on 05/05/25, with an administration time of 05/05/25 at 8:43pm and a documentation time of 11:44pm on 05/05/025 by V13. Lipitor Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime, with a schedule date of 05/04/25 at 9pm, an administration time of 05/05/25 at 12:14am and a documentation time of 12:19am on 05/05/25 by V24 (RN). This same medication was scheduled for 9pm on 05/05/25, with an administration time of 05/05/25 at 8:44pm, with a documentation time of 11:44pm on 05/05/25 by V13. Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime, with a schedule date of 05/04/25 at 9pm, an administration time of 05/05/25 at 12:19am and a documentation time of 12:19pm on 05/05/25 by V24 (RN). This same medication was scheduled for 9pm on 05/05/25, with an administration time of 05/05/25 at 8:43pm and a documentation time of 11:44pm on 05/05/25 by V13. On 05/06/25 at 09:09am, R8 stated he did not receive his PM medications from last night until two-thirty this morning. 3. R37's admission Record documented an admission date of 09/20/23 and included diagnoses of Chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. R37's MDS assessment dated [DATE] documented a BIMS score of 13, indicating R37 is cognitively intact. R37's Medication Admin Audit Report documents the following physician's orders: Furosemide Oral Tablet 40 MG (Furosemide) Give 40mg by mouth three times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth two times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. Melatonin Oral Tablet 3 MG (Melatonin) Give 2 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. On 05/07/25 at 11:13am, R37 stated she wished she received her medications on time. R37 stated that when V13 (LPN) works they rarely receive their medication before midnight. R37 commented that these medications should be passed around 7 or 8pm. On 05/08/25 at 9:39am, V3 (Assistant Director of Nursing/ADON) stated nurses are expected to be documenting the administration of medications as they are administering them, as that is according to professional standards of practice and reduces the risk of medication errors. The facility's Medication Administration Policy/Procedure with a revision date of 09/27/22 documents the following under Policy: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL's) in a timely manner for 3 (R6, R7, and R24) of 19 residents reviewed for ADL assistance in a sample of 46. Residents Affected - Few Findings include: 1. R7's admission Record documents an admission date of 05/27/2020 with diagnoses that included type 2 diabetes mellitus, dementia, unspecified psychosis not due to a substance or known physiological condition, chronic kidney disease, and history of transient ischemic attack and cerebral infarction. R7s Minimum Data Set (MDS) assessment dated [DATE] documents no Brief Interview for Mental Status (BIMS) score was conducted due to resident is rarely/never understood. Under the section for Functional Abilities and Goals, the MDS documented R7 needed supervision or touching assistance for eating, indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 05/06/25 at 12:01 PM, R7's lunch was removed from the tray and placed in front of her. R7 was sitting in her wheelchair, asleep with her head leaned forward and to the side. Staff did not attempt to awaken R7 to eat her lunch at this time. On 05/06/25 from 12:01 PM to 12:40 PM, R7's food sat in front of her uncovered with R7 sleeping at the table and no staff attempting to wake her or see if she wanted to eat lunch. On 05/06/25 at 12:40 PM, V15 (Food Service Director) woke R7 up and encouraged her to eat her lunch. On 05/06/25 at 12:42 PM, V6 (Certified Nurse Aide/CNA) moved R7's food plate and drinks to another table then moved R7 to that table and assisted her with her lunch. On 05/08/25 at 1:57 PM, V15 stated she does not know why V6 moved R7's lunch to a different table to assist R7, she should not do that. On 05/08/25 at 2:00 PM, V3 (Assistant Director of Nursing/ADON) stated, staff should not wait 40 minutes to wake someone up and encourage them to eat; after 40 minutes their food would be cold. 2. R24's admission Record documents an admission date of 04/21/2018 and included diagnoses of facial weakness following other cerebrovascular disease, dementia, type 2 diabetes mellitus, anxiety disorder, and major depressive disorder. R24's MDS dated [DATE] documented a BIMS score of 04, indicating R24 has severe cognitive impairment. Under the section for Functional Abilities and Goals, the MDS documented R24 needed supervision or touching assistance for eating, indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm On 05/06/25 at 12:03 PM, R24 attempted to drink her chopped fruit fluff with her straw. The chopped fruit fluff was unable to move through the straw due to the thick consistency and chopped fruit. On 05/06/25, from 12:03 PM to 12:40 PM, R24 tried to eat her dessert with her straw and did not touch any of the rest of her food. Residents Affected - Few On 05/06/25 at 12:40 PM, V16 (CNA Supervisor) asked R24 if she would prefer to use a spoon. V16 picked up R24's spoon, put it in her hand, and put the straw down on the table. V16 then encouraged R24 to eat some of her lunch. On 05/06/25 at 12:41 PM, R24 started eating her dessert and then continued to eat some of her other food. On 05/08/25 at 2:03 PM, V3 (ADON) stated staff should have noticed R24 had not eaten any of her lunch, was trying to eat her dessert through a straw, and should have and assisted R24 before allowing her to attempt to eat her dessert with through a straw for over 40 minutes. 3. R6's admission Record documented an admission date of 10/12/21 and included diagnoses of dementia, type 2 diabetes mellitus, and hearing loss. R6's MDS assessment dated [DATE] documented no BIMS score was conducted due to resident is rarely/never understood. R6's Bowel and Bladder assessment dated [DATE] documents: 1. a. void appropriately without incontinence: with 'never' marked. On 05/05/25 at 12:34 PM, R6 was sitting in the dining room in her wheelchair with her pants wet from just below her waist to almost her knees. There was urine under her wheelchair causing a puddle over 12 inches across and over six inches wide. On 05/05/25 between 12:34 PM and 1:33 PM, R6 sat in the dining room eating her lunch while wet with a puddle of urine underneath her and several staff walking by and not asking to change her or covering the puddle of urine. On 05/05/25 at 1:33 PM, V17 (CNA) put a towel over the urine, went and acquired gloves, cleaned the urine and removed R6 and the towel from the dining room. On 05/05/25 at 1:36 PM, V17 took R6 to get changed. On 05/08/25 at 2:00 PM, V3 (ADON) stated staff should have assisted R6 out of the dining room, cleaned her up, changed her clothes and brought her back to the dining room to eat the rest of her lunch. They could have put a cover over her food to keep it warm while they quickly changed her. V3 stated she would have expected housekeeping to discretely clean the urine from the floor. She would not want a resident to sit for an hour, wet in the dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement new interventions to prevent falls for 2 (R27 and R63) of 4 residents reviewed for accidents/supervision in the sample of 46. The Findings include: 1. R27's admission record dated 05/08/25 documents an admission date of 07/22/22 with diagnoses in part of lack of coordination, abnormal posture, unsteadiness on feet, disorder of bone density and structure, and repeated falls. R27's Minimum Data Set (MDS) dated [DATE] documents under Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, indicating R27 is cognitively intact. Under Functional Abilities and Goals, the MDS documents R27 needs supervision or touching assist with toileting and walking. A facility Initial Incident report in the electronic health record dated 04/28/25 documents R27 experienced a fall. This document includes a progress note of the incident that states: in part of CNA (Certified Nurse Assistant) called this nurse to hall et stated resident was observed on the floor in his room. Upon assessment, resident noted right side of bed A in room. Stated his bed was not made so he was going to lay down in the other bed. Unable to stated [sic] what he was doing other than attempting to lay down. Feet observed toward HOB (head of bed) with legs extended out and laying on right side facing the doorway. Denies hitting head. Fall un-witnessed. No visible injuries noted. Resident assisted back into bed via 2 staff and gait belt. Stated he wanted to lay down. Denies pain . R27's Care Plan documents a focus area of: At risk for falls and injuries r/t (related to) Medication: Psychotropic meds/diuretic meds/Cardiovascular meds/pain meds/impaired mobility/weakness with a revision date of 08/02/22. Interventions include therapy and nursing to educate resident on safe walking practices based on how is feeling at the time of ambulation (initiated on 09/13/24), call don't fall sign at bedside (initiated 07/03/24), diabetic medication review by MD (Medical Doctor) (medications changed and labs ordered) (initiated 03/03/23), encourage use of call light, keep call light within reach, keep environment clutter free, keep personal belongings within reach, and provide adequate lightening (all initiated on 07/22/22). There were no new interventions documented on R27's care plan after the fall on 4/28/25. On 05/05/25 at 11:31AM, R27 stated that he did have a recent fall and a history of falling. R27 stated that he doesn't know of any interventions that the facility has put in place to prevent him from falling again. On 05/07/25 at 10:35AM, V3 (Assistant Director of Nursing/ADON) stated that they don't have a root cause analysis done for R27's falls. V3 stated that there should have been one done on R27's fall and she doesn't know why there wasn't. On 05/08/25 at 11:33AM, V11 (MDS/Care Plan Coordinator) stated that R27 had no new interventions after his fall on 04/28/25. V11 stated that she wasn't working at the facility at that time as she only recently started at the facility. 2. R63's admission Record documents an admission date of 02/19/25 and included diagnoses of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Parkinson's disease without dyskinesia and type 2 diabetes mellitus without complications. Level of Harm - Minimal harm or potential for actual harm R63's MDS dated [DATE] documented a BIMS score of 13, indicating that R63 is cognitively intact. Residents Affected - Few R63's Care Plan documented R63 is at risk for falls and injuries related to Parkinson's. This focus area has an initiation date of 02/19/25. There are no new interventions documented on R63's current care plan after 03/18/25. A facility Incident Report with an incident date of 03/20/25 at 9:00pm, documents that while R63 was attempting to transfer herself, she fell on her knees resulting in abrasions to the left and right knee and a bruise . There were no new fall interventions listed on this document. A facility Incident Report with an incident date and time of 05/02/25 at 12:00pm, documents R63 reported that she was getting up and she fell approximately 5 days prior. R63 stated she did not report it to nurse as she didn't feel she was hurt. This report also added an injury 5/4/25 that a bruise was noted to R63's chin left side a few days post fall. There were no new interventions listed on this document. On 05/06/25 at 11:43am, R63 stated she has had some falls recently, but she couldn't be sure when they were or what the facility did. R63 stated she did go to the hospital after her first fall and the bruise she currently has on her chin is from a fall last week. On 05/07/25 at 10:35am, V3 (ADON) stated they do not have root cause analysis for R63. V3 confirmed that there were no new interventions for R63's most recent falls. The facility policy titled Accident and Incidents with a revised date of 09/07/23 documents in part under policy: The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions Facility policy titled, Accidents and Incidents with a revision date 09/07/23 documents the following under policy; All accidents/incidents involving a resident shall require an incident report .The interdisciplinary team will complete an investigation to determine root cause and implement appropriate interventions. In the section titled policy interpretation and implementation it documents in part, .appropriate interventions will be indicated in the incident report and implemented. The MDS (Minimum Data Set) nurse shall update the care plan with implemented interventions and communicate interventions with line staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sanitary food service by not performing hand hygiene. This failure has the potential to affect all 64 residents residing at the facility. Findings include: 1. On 05/05/25 at 12:35 PM, V17 (Certified Nurse Aide/CNA) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/06/25 at 12:03 PM, throughout lunch service V4 (CNA) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/06/25 at 12:07 PM, throughout lunch service V5 (Housekeeping Supervisor) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the dietary cart door, the handles of a wheelchair, and her sweater with no hand hygiene in between. On 05/06/25 at 12:16 PM, throughout lunch service V6 (CNA) transferred glasses onto residents lunch trays by the rim area where the resident would drink from after touching the back of three dining room chairs and her top with no hand hygiene in between. On 05/07/25 at 11:40 AM, throughout lunch service V7 (CNA) transferred glasses onto residents' lunch trays by the rim area where the resident would drink from after touching the back of dining room chairs and her pants with no hand hygiene in between and then transferred the glasses by the rim area onto the table for the residents. On 05/07/25 at 12:09 PM throughout lunch service V8 (CNA) transferred glasses onto residents lunch trays by the rim area where the resident would drink from after touching the handles of five wheelchairs with no hand hygiene in between and then transferred the glasses by the rim area onto the table for the residents. On 05/07/25 at 12:12 PM, while assisting four residents with condiments on their burgers, V4 (CNA) touched the top buns after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/08/25 at 1:54 PM V15 (Food Service Director) stated, staff should not touch the top of the glasses where the residents drink from after touching anything that is not a clean sanitized item and they should not be touching resident's food items if their hands are not clean or if they don't have clean gloves on. R22's admission Record dated 05/08/25 documents an admission date of 08/08/24 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, aphasia following other cerebrovascular disease and type 2 diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 04, which indicates severely impaired cognition. R22's MDS also documented R22 requires supervision or touching assistance with eating. R22's Care Plan documents a focus area of: Altered Nutrition and hydration (Risk) r/t (related to) GI (gastrointestinal) disturbance. Another focus area documents: Self-Care deficit as evidenced by needs assistance with ADL'S (Activities of Daily Living). Interventions include in part: Eating -supervision to one person physical assist required. On 05/06/25 at 12:25PM, V12 (CNA) served R22 her tray. V12 grabbed the top of R22's drinking glasses by the rims around the mouthpiece to place R22's glasses on the table. V12 then gave several bites of food to R22, then got up to go punch in the code to the smoking door to assist other residents in from smoking. V12 then went back to assisting R22 to eat without performing hand hygiene after touching other residents, the keypad and the door. On 05/06/25 at 12:35PM, V12 grabbed a spoon from another resident who had her hand on the end of the spoon and used it to stir R22's sugar into her tea. On 05/06/25 at 12:36PM, V12 got up again from assisting R22 with eating to go open the smoking door for severals resident that were outside smoking. V12 was punching in the code to the door and assisting residents in. V12 then went back to assisting R22 to eat without performing hand hygiene. On 05/06/25 at 12:45PM, V12 got up once more to go punch the code in for the smoking door and assisting residents in from outside, then went back to assisting R22 to eat without performing hand hygiene. On 05/08/25 at 9:14AM, V12 stated that she did not perform hand hygiene at anytime when she kept getting up from assisting R22 to eat and opening the door to let the smokers in or after she assisted other residents back in from being outside smoking. V12 stated that she did not perform hand hygiene before serving R22's tray. V12 stated that she knows she grabbed R22's glass by the top of the glass around the mouth area. V12 stated that she has nerve damage in her neck and can't grab a cup by the side or the glass will fall out of her hand. V12 said that she grabs all resident glasses by the top around the the mouth area because she doesn't want to drop a cup. V12 didn't know if this was sanitary or not. V12 said that she should of performed hand hygiene each time she came back from opening the door to let the smokers in and every time she touched another resident. 3. R42's admission Record dated 05/12/25 documents an admission date of 04/22/22 and included diagnoses of systemic lupus and severe sepsis. R42's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment and documented R42 requires set-up or clean-up assistance. R42's Care Plan documented a focus area of: R42 has impaired immunity r/t (related to) lupus with a revision date of 12/15/22. Interventions include in part: The resident is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infection away. On 05/06/25 at 12:18PM, V15 (Food Service Director) served R42 his tray. V15 grabbed R42's drinking glasses by the tops of the glass around the mouth area to set them down on the table. V15 did not perform hand hygiene before serving R42's tray and glasses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 4. R44's admission Record dated 05/12/25 documents an admission date of 06/24/22 and included diagnoses of Alzheimer's disease and type 2 diabetes mellitus. R44's MDS dated [DATE] documented a BIMS score of 03, indicating severe cognitive impairment. The MDS also documented R44 requires set-up or clean-up assistance. Residents Affected - Many R44's Care Plan documents a focus area of: Altered nutrition and hydration risk, dx (diagnosis) of Alzheimer's' disease, diabetes. On 05/07/25 at 12:21PM, V15 (Food Service Director) served R44 his tray. V15 grabbed R44's drinking glasses at the top of the glass around the mouth area without performing hand hygiene prior to serving R44's tray. The facility policy titled Handwashing/Hand Hygiene undated documents under policy statement The facility considers hand hygiene the primary means of preventing the spread of infection. Under Policy interpretation and implementation, #7 Use of alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: B: Before and after direct contact with residents, O: Before and after assisting a resident with meals. The Long Term Care Facility Application for Medicare and Medicaid dated 05/05/25 documents 64 residents residing at the facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Transmission-Based Precautions were followed for 1 (R29) of 3 residents reviewed for Infection Prevention and Control in the sample of 46. Residents Affected - Few Findings include: R29's admission Record documented an admission date of 05/28/21 and included diagnoses of osteomyelitis, unspecified, cutaneous abscess of left foot, cellulitis of left lower limb, and gangrene. R29's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating that R23 is cognitively intact. R29's Physician's Order Sheet (POS) dated 05/12/25, documents an active order through 5/6/25 for Contact isolation r/t (related to): MRSA (Methicillin-resistant Staphylococcus aureus) to Lt (left) foot wound, every shift for MRSA. R29's Progress Note dated 5/5/2025 at 10:29 AM documented continues IV (intravenous) antibiotic therapy. Tolerating well, no s/s (signs and symptoms) reaction. Picc (peripherally inserted central catheter) line in place, patent. Remains on isolation precautions as ordered. On 05/05/25 at 2:47 PM, R29's room did not have any transmission-based precautions signage posted on or around the door. There was Personal Protective Equipment (PPE) noted outside the next room down from R29's room, but not right outside R29's room. There were no biohazard barrels observed in R29's room. On 05/05/25 at 2:52 PM, R29 stated he is on IV antibiotics for an infection in his foot. R29 stated no one wears gowns or anything when providing care for him. R29 stated he has been told he was on isolation before but wasn't really sure what that means. On 05/06/25 at 9:05 AM, R29's room was again observed to not have any transmission-based precautions signage posted on or around the door. There was PPE noted outside the next room down from R29's room but not right outside R29's room. R29's Progress Note dated 05/06/25 at 10:00am states, Spoke to (name of doctor) office. Orders obtained to d/c (discontinue) (antibiotic), d/c picc line, and d/c isolation. On 05/07/25 at 12:36 PM, V6 (Certified Nursing Aide/CNA) stated R29's hallway is her regular assignment and there were no precautions in place for R29 when he had his wound and PICC line. V6 stated they were not required to wear any PPE when providing care for R29. On 05/08/25 at 2:06 PM, V18 (Infection Preventionist) stated R29 was taken off isolation on 05/06/25 when his antibiotic was finished. V18 stated R29 was on contact precautions for MRSA. V18 stated there should be signs and PPE outside of a resident's room who is on any kind of precautions. V18 stated PPE should be worn when providing care for someone on contact isolation. Facility Policy titled, Initiating Isolation Precautions with a revision date of 12/06/21 documents in Policy interpretation and implementation, When Transmission-Based Precautions are implemented, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Infection Preventionist (or designee): a. Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. b. Explains to the resident (or representative) the reason(s) for the precautions. c. Provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE. d. Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. (1) The signage informs the staff of the type of CDC (Center for Disease Control) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. (2) Signs and notifications comply with the resident's right to confidentiality or privacy. e. Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. f. Ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and g. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, (red bags) are placed in the resident's room. 4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met. Event ID: Facility ID: 145649 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer pneumococcal immunizations as ordered by a physician for 2 (R2 and R21) of 5 residents reviewed for immunizations in the sample of 46. Residents Affected - Few Findings Include: R2's admission record dated 05/13/25 documented an admission date of 06/16/22 and included diagnoses of Alzheimer's, unspecified atrial fibrillation, abnormal thyroid function, and thrombocytosis. R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not conducted as resident is rarely/never understood, and the staff assessment documented R2 has short- and long-term memory problems. R2's Care Plan with a revision date of 04/14/24 documented a Focus Area of Self-Care Deficit as Evidenced by: Needs assistance with ADL (Activities of Daily Living). R2's Order Review report documented Prevnar 20 Intramuscular suspension Prefilled syringe 0.5Ml (Milliliters) inject 0.5 ML intramuscularly every day shift for vaccination for 1 day. Order status documents Completed. The order date is documented as 04/12/24, Start date of 04/16/24, End date of 04/17/24. R2's Medication Administration Record (MAR) from 04/01/24 to 04/30/24 documents Prevnar 20 Intramuscular suspension Prefilled syringe 0.5ML (Milliliters) inject 0.5 ML intramuscularly every day shift for vaccination for 1 day with an order date of 04/12/24. The date of 04/16/24 has V25's (Licensed Practical Nurse/LPN) initials and the Letters MN. The Chart Code on the MAR documents MN=Medication not Available. R2's clinical Immunizations record documents Prevnar 20 Administration date 04/16/24 administered by V25 (LPN). On 05/08/25 at 2:24PM, R2's Prevnar 20 vial was observed in the refrigerator of the medication room with a delivery date of 04/15/24. Instructions document Prevnar 20 Intramuscular suspension Prefilled syringe 0.5Ml (Milliliters) inject 0.5 ML intramuscularly. On 05/08/25 at 2:35PM, V2 (Director of Nursing/DON) stated the reason R2's Prevnar 20 dated 04/16/24 was still in the refrigerator in the medication room was because someone didn't administer it and they would have to start the process over and get a new order to give the Prevnar 20 to R2. On 05/12/25 at 12:00PM, V25 (LPN) stated that she did not give R2 her Prevnar 20 vaccine. V25 stated that she signed the MAR that the medication was not available, as she was unable to find the Prevnar 20 to administer it to R2. V25 stated that she doesn't know why on the immunization record that it is documented that she gave R2 her Prevnar 20 because she did not give it. 2. R21's admission Record documented R21 was [AGE] years old and admitted to the facility on [DATE]. This document also included diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of bladder, acute kidney failure, and personal history of malignant neoplasm of breast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odin Health and Rehab Center 300 Green Street Odin, IL 62870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 R21's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm R21's Care Plan with a revision date of 09/30/24 documented a focus area of Self-Care Deficit as evidenced by: Needs assistance with ADL's. Residents Affected - Few R21's Order Review report documents an order summary for Prevnar 20 Intramuscular Suspension Prefilled syringe 0.5 ML (milliliters) inject 0.5 ML intramuscularly one time only for preventative . Order status documents Completed. The Order date is documented as 03/13/25, Start date of 03/17/25, End date of 03/20/25. R21's MAR form 03/01/25 to 03/31/25 documents Prevnar 20 Intramuscular Suspension Prefilled syringe 0.5ML (Pneumococcal 20-Valent Conjugate Vaccine) inject 0.5 ML intramuscularly one time only for preventative . Order date documents 03/13/25. On 3/17/25, V25's (LPN) initials were listed along with the MN. The Chart Code on the MAR documents MN=Medication not Available. On 05/08/25 at 2:24PM, R21's Prevnar 20 vial was observed in the medication room refrigerator with a delivery date of 03/13/25 and instructions document Prevnar 20 Intramuscular suspension Prefilled syringe 0.5Ml (Milliliters) inject 0.5 ML intramuscularly. On 05/08/25 at 2:35PM, V2 (DON) stated the reason R21's Prevnar 20 injection vial was in the medication storage refrigerator is because someone probably didn't give it and they would have to start the whole process over with getting consent, the order for the medication as well since it wasn't given. On 05/12/25 at 12:00PM, V25 (LPN) stated that she did not give R21 her Prevnar 20 vaccine. V25 stated that she signed the MAR that the medication was not available, as she was unable to find the Prevnar 20 to administer it to R21. V25 stated that she did not give R21 her Prevnar 20 injection. The facility policy titled Pneumococcal Vaccine with a revised date of 05/18/22 documents under purpose as To protect residents for the dangers for pneumonia infection. Under Policy Interpretations and implementations, #4. Pneumococcal vaccine will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145649 If continuation sheet Page 18 of 18