Health inspection·September 10, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete providing showers and documenting if the shower was given and/or refused. V2 Director of Nurses (DON) stated residents are scheduled for two showers per week. V2 DON stated if the resident refuses for any reason, that refusal should be documented. V2 DON stated providing showers/bed baths for residents is an important part of their overall health and hygiene. V2 DON stated the facility does not have a specific policy for providing showers/bed baths but would expect that new residents would receive their first shower/bed bath within the first 24 hours and existing residents are to receive a shower/bed bath twice weekly unless they refuse which staff should be documenting. The facility policy titled Resident Care Policy and Procedure revised October 17, 2024, documents staff are to provide morning cares which include oral care, shaving, trimming nails, providing perineal care and dressing resident. Dress or assist resident to dress in clean, comfortable clothing, including shoes, stockings or socks and underwear. Provide assistance with shaving (both male and female). Event ID: Facility ID: 145772 If continuation sheet Page 2 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 complete a wound assessment, monitor skin integrity, and prevent cross contamination during wound care and incontinence care for three of three residents (R1, R2, R3) reviewed for pressure sores in the sample list of ten residents. Findings include:1.R1's undated Face Sheet documents R1 admitted to the facility on [DATE] and was discharged on 8/30/25. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses as Muscle Wasting, Nontraumatic Intracerebral Hemorrhage, Diabetes Mellitus Type II, Atrophy, Convulsions, Chronic Vascular Disorders of Intestine, Chronic Obstructive Pulmonary Disease (COPD), Urinary Tract Infection (UTI), Dysphagia Oral Phase, Hypertension, Depression, Dependence on Supplemental Oxygen, Gastrostomy Status, Neuromuscular Dysfunction of Bladder, Acute Respiratory Failure with Hypoxia, Chronic Kidney Disease, Glaucoma, Anemia and Hyperkalemia. R1's admission assessment dated [DATE] does not document a pressure ulcer for R1. R1's Care Plan interventions dated 8/22/25 documents staff are to Instruct R1 on the importance of positioning/shifting weight and proper body alignment. Encourage/remind/assist R1 to change positions/shift weight with Activities of Daily Living (ADL) and rounds. R1's Pressure Ulcer Risk assessment dated [DATE] documents R1 as being a high risk for pressure ulcers.R1's Physician Order Sheet (POS) dated August 2025 documents a physician order starting 8/24/25 to cleanse R1's Coccyx, apply Triad cream and cover with a bordered foam daily. This same POS documents a physician order starting 8/21/25 to complete a daily skin check. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as being dependent on staff for total assistance for eating, oral hygiene, dressing, bathing, toileting and bed mobility. This same MDS documents R1's transfer status was not attempted due to medical condition or safety concerns.R1's Skilled Evaluation Progress Notes dated 8/21/25 at 5:39 AM, 8/22/25 at 3:16 AM and 8/23/25 at 2:40 AM that includes skin evaluations does not document R1's Sacral Pressure Ulcer. There is no Skilled Evaluation documented for 8/24/25. R1's Nurse Progress Note dated 8/23/25 at 5:52 PM documents During (R1) care when wiping (feces) off of Coccyx (R1's) skin wiped off. Skin is friable.R1's Hospital Record dated 8/24/25 documents a referral to the hospital wound team.R1's Hospital Record dated 8/25/25 documents R1's Wound #1 Sacrococcygeal Pressure Ulcer measuring 8.0 centimeters (cm) long by 10 cm wide by 0.1 cm deep with peeling, deep red, moist skin and a small amount of serosanguineous drainage as Unstageable, likely Stage 3 or Stage 4. This same wound note documents R1's Wound #1 peri wound as peeling deep purple and non-blanchable discoloration with pain noted with cleansing/palpation.On 9/6/25 at 11:50 AM V5 Licensed Practical Nurse (LPN) stated R1 admitted to the facility on [DATE] after suffering a Cerebrovascular Accident (CVA). V5 LPN stated she was R1's nurse on 8/23 and 8/24. V5 LPN stated on 8/23/25 V25 Certified Nurse Aide (CNA) informed V5 that during incontinence care for R1 a 'sore' was noted. V5 LPN stated she finished her medication pass and then assessed R1's Sacrum area. V5 LPN stated it looked like R1's skin 'just wiped off.' V5 LPN stated R1's Sacrum was purple and bleeding. V5 LPN stated V5 did not fully assess nor measure R1's open Sacral wound. On 9/9/25 at 11:20 AM V25 Certified Nurse Aide (CNA) stated V25 was assisting R1 with incontinence care at supper time on 8/23/25. V25 CNA stated R1's ‘skin fell off of his bottom.' V25 CNA stated R1's bottom looked ‘terrible.' V25 CNA stated V5 Licensed Practical Nurse (LPN) entered R1's room to place a bandage over R1's Sacral wound. V25 CNA stated V5 LPN stated R1's Sacral pressure ulcer looked ‘awful.' 2.R2's Electronic Medical Record (EMR) documents R2's medical diagnoses as Cerebral Palsy, Unstageable Sacral Ulcer, Dysphagia, Colostomy Status, Urogenital Implants, Esophageal Obstruction, Hearing Loss, Iron Deficiency Anemia, Chronic Respiratory Failure with Hypoxia and Hypercapnia, Hypertension, Diabetes Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 3 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Mellitus Type II, Barrett's Esophagus without Dysplasia, Urinary Tract Infections (UTI), Extended Spectrum Beta Lactamase Resistance, Profound Intellectual Disabilities, Neuromuscular Dysfunction of Bladder, Obstructive Sleep Apnea, Dependence on Supplemental Oxygen, Dependence on wheelchair, Sepsis, Hypertensive Heart Disease without heart failure and History of Left Hip Pressure Ulcer.R2's Care plan intervention dated 7/24/25 documents Assess my skin per policy. Daily if moderate risk or higher, or if wound present. R2's Pressure Ulcer Risk assessment dated [DATE] documents R2 has very limited sensory perception, chairfast and ‘does not make even slight changes in position without staff assistance.' R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 is dependent on staff for total assistance with eating, oral hygiene, dressing, bathing, toileting, bed mobility and transfers. R2's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 7/28/25 with no end date to complete daily skin checks.R2's Treatment Administration Record (TAR) dated August 2025 documents a physician order starting 7/28/25 to assess R2's skin daily and document a progress note every night shift. This same TAR shows that Licensed Nursing staff completed R2's nightly skin checks on 8/4/25 and 8/5/25. R2's Skilled Evaluation Progress Note dated 8/5/25 at 12:51 AM includes a skin evaluation that does not document R2's Stage 4 Sacral Pressure Ulcer. R2's Nurse Progress Note dated 8/5/25 at 10:23 AM documents R2 has an open area to his Coccyx. This same note documents R2's Coccyx open area measures 6.5 centimeter (cm) long by 7.5 cm wide area with no depth documented. R2's Initial Wound Evaluation and Management Summary dated 8/7/25 documents R2's Unstageable Sacrum Pressure Ulcer as full thickness, having moderate serous drainage, 50% thick adherent devitalized necrotic tissue and measuring 7.2 cm long by 6.0 cm wide by unmeasurable depth. R2's Wound Care Progress Report dated 8/14/25 documents R2's Sacrococcygeal Pressure Ulcer as Unstageable 'likely Stage 3 or 4,' with mostly nonviable tissue, serosanguineous drainage and measuring 5.0 centimeters (cm) long by 5.0 cm wide by 0.1 cm deep. R2's Wound Evaluation and Management Summary dated 8/28/25 documents R2's Sacral Pressure Ulcer as a Stage 4 after sharp debridement. This same summary documents R2's Stage 4 Sacral Pressure Ulcer as measuring 6.0 cm long by 7.0 cm wide by unmeasurable depth with moderate serous drainage and 60% thick, adherent, devitalized, necrotic tissue. R2's Wound Evaluation and Management Summary dated 9/4/25 documents R2's Stage IV Pressure Ulcer as measuring 6.0 cm long by 7.0 cm wide by 1.0 cm deep with 1.5 cm undermining at 5 o'clock. This same summary documents R2's Stage IV Pressure Ulcer as having 40% thick, adherent, devitalized tissue and moderate serous drainage. This same summary documents R2's Sacral Pressure Ulcer as exacerbated. On 9/7/25 at 9:20 AM V18 (R2) Power of Attorney (POA) stated the facility called him (8/5/25) to let him know R2 has a pressure sore on his buttocks. V18 stated the day before (8/4/25) he was visiting R2 and noticed that his wheelchair seat cushion was turned sideways while R2 was sitting in his wheelchair. V18 stated R2's wheelchair is a specialized cushion made to fit in R2's motorized wheelchair a certain way. V18 stated R2's wheelchair cushion is rectangular shaped, and it should be placed so that the longest part should be placed from side to side. V18 stated on 8/4/25 the longest part of R2's seat cushion looked like it had been shoved up underneath (R2). V18 stated it was wrinkled and bulky. V18 stated the staff could have caused R2's Sacral pressure ulcer by placing R2's specialized cushion incorrectly. On 9/7/25 at 1:20 PM V9 Registered Nurse (RN) and V10 Certified Nurse Aide (CNA) completed wound care for R2. V9 RN and V10 positioned R2 on his Right side on his bed. R2's was laying on an incontinence pad that showed a moderate amount of wound drainage. V9 RN nor V10 CNA provided a clean field for R2's Stage 4 Sacral Pressure Ulcer care. During wound care, V9 RN placed a Calcium Alginate pad over R2's open Stage 4 Sacral Pressure Ulcer. R2's contaminated incontinence pad made full contact with R2's Calcium Alginate pad. V9 RN placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 4 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the new dressing directly over R2's contaminated Calcium Alginate pad. R2's Stage 4 Sacral Pressure Ulcer was open with a moderate amount of serosanguinous drainage, grey soft adherent wound bed and dark pink periwound. On 9/7/25 at 1:40 PM V9 Registered Nurse (RN) stated it is important to provide a clean field to prevent cross contamination and infection. V9 RN stated R2 is reliant on staff for all cares. V9 RN stated I hope I put on the right dressing. I didn't look at the Physician orders first. I just put on the same dressing from the last time I took care of (R2) a week or so ago. 3.R3's Electronic Medical Record (EMR) documents R3's medical diagnoses as Hypertension, Osteoarthritis, Peripheral Vascular Disease, Dementia, Psychotic Disturbance, Mood Disturbance, Atrial Fibrillation, Muscle Weakness, Abnormalities of gait and mobility and Unsteady on feet.R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring total assistance from staff for eating, oral hygiene, dressing, bathing, toileting, personal hygiene, bed mobility and transfers. R3's Pressure Ulcer Risk assessment dated [DATE] documents R3 as being at high risk for skin breakdown. R3's Ulcer assessment dated [DATE] documents R3 obtained a pressure ulcer during her stay at the facility. This same assessment documents R3's Pressure Ulcer is located on her Coccyx and measures 0.3 centimeters (cm) long by 0.3 cm wide by 0.2 cm deep. R3's Physician Order Sheet (POS) dated September 2025 documents an updated physician order starting 8/21/25 to Cleanse coccyx area with wound wash or normal saline. Apply skin prep to peri wound then apply Triad hydrophilic paste to wound bed and cover with border foam. This same POS documents a physician order starting 7/24/25 to complete a daily skin check. On 9/7/25 at 9:35 AM V10 and V20 Certified Nurse Aide (CNA) completed incontinence care for R3. R3 did not have a dressing covering her open Sacral pressure ulcer. V20 CNA wiped urine and feces directly over R3's open Sacral pressure ulcer. On 9/7/25 at 10:00 AM V19 Licensed Practical Nurse (LPN) completed wound care for R3's Sacral pressure ulcer. R3 did not have a covering over her Sacral pressure ulcer. V19 LPN described R3's Sacral pressure ulcer as having a red center with white edges and measuring 'about' 0.5 centimeters (cm) long by 0.5 cm wide by 0.5 cm deep. V19 LPN knelt down with both of her knees and lower legs touching the floor while competing R3's Sacral Pressure Ulcer care. V19 LPN did not change gloves nor use hand hygiene between cleansing R3's Sacral pressure ulcer and applying R3's treatment and new bandage. On 9/8/25 at 9:35 AM V15 Licensed Practical Nurse (LPN)/Wound Nurse stated any time a new wound is found the nurse should complete a full skin assessment of the resident. V15 Wound Nurse/LPN stated the floor nurse should complete the Pressure Ulcer Risk Assessment, Nurse Progress Note, Ulcer Assessment, obtain treatment order and notify all necessary parties. V15 stated R1 did not admit to the facility with any pressure ulcers. V15 stated R1's Sacral Pressure Ulcer was facility acquired and first noted on 8/23/25. V15 Wound Nurse/LPN stated she was not aware R1 had any kind of wounds until 9/6/25. V15 Wound Nurse/LPN confirmed R1 had a ‘significant' sized facility acquired Sacral Pressure Ulcer that was not assessed, monitored or care planned for R1. V15 Wound Nurse stated she was not aware that R2 had a specialized cushion in his wheelchair. V15 Wound Nurse stated all medical devices have the potential of causing pressure sores and staff should be careful when using any medical device to try to prevent pressure ulcers. V15 Wound Nurse stated cross contaminating an open wound such as R2 and R3's Sacral Pressure Ulcers could cause an infection in those wounds which would be detrimental for R2 and R3. V15 Wound Nurse stated the facility nurses are ‘signing out' daily skin checks as being completed. V15 Wound Nurse stated if the facility nurses are completing daily skin checks they are not doing full skin assessments as they should be or R1 and R2's Sacral Pressure Ulcers would have been identified prior to them being significant wounds. V15 Wound Nurse/LPN stated V15 completes the facility weekly wound measurements every Tuesday and rounds with V14 Wound Physician every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 5 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Thursday. V15 Wound Nurse/LPN stated every Tuesday she does a ‘seven day look back' to see if any of the residents have any new wounds. V15 Wound Nurse/LPN stated she does not review shower sheets for residents. On 9/9/25 at 9:25 AM V2 Director of Nursing (DON) stated any new wound or skin alteration should be fully assessed and documented to ensure continuity of care for the resident. V2 DON stated although V5 Licensed Practical Nurse (LPN) did obtain a treatment order for R1's Sacral wound, the extent of the wound was unknown due to a full wound assessment was not completed. On 9/10/25 at 1:25 PM V23 Medical Director stated V5 LPN should have fully assessed and documented R1's Sacral Pressure Ulcer. V23 Medical Director stated R1 was very medically compromised prior to his admission to the facility, remained ‘very ill' during his stay and through his stay at the hospital from 8/24-8/29/25. V23 Medical Director confirmed R1, R2 and R3's Sacral Pressure Ulcers were all facility acquired. V23 Medical Director stated he believed R1 was ‘breaking down internally' which was not able to be detected. V23 stated he did not visualize R1's Sacrum during his assessment of R1 onsite on 8/22/25. V23 Medical Director stated he could not assign a cause to R1, R2 or R3's Sacral Pressure Ulcers. V23 Medical Director stated staff should fully document any new pressure ulcer, ensure medical devices are placed appropriately and follow applicable Infection Control policies when caring for residents' wounds. The facility policy titled Dressing Change Aseptic Technique revised April 13, 2021, documents nursing staff should assemble dressing materials on a clen field. Perform hand hygiene, remove the old dressing, remove and dispose of contaminated gloves. Perform hand hygiene, apply clean gloves, cleanse wound then remove and dispose of gloves. Perform hand hygiene, apply clean gloves. Apply dressing. Remove gloves and dispose of contaminated waste material. Perform hand hygiene. The facility policy titled Wound and Ulcer Policy and Procedure revised March 8, 2024 documents when an existing or newly developed pressure ulcer's' is present, a skin assessment (skin check) will be documented each shift to monitor the individual resident's tolerance to the current repositioning schedule (tissue tolerance) and the facility will re-evaluate the frequency of repositioning if indications of further breakdown occur. Approaches will be placed in the resident's care plan. When a resident is found to have a wound a licensed nurse will document assessment of the wound/ulcer in the medical record. Pressure injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant ulcer generally conforms to the pattern or shape of the device. Should be staged to the most severe tissue damaged depth. Residents with any type of medical device in place should be assessed at least twice a day for possible skin injury. Event ID: Facility ID: 145772 If continuation sheet Page 6 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide palatable foods for four residents (R1, R4, R6, R7) out of four residents reviewed for Dietary Services in a sample list of ten residents. Findings include: The facility menu dated Week 1 Saturday (9/6/25) documents Beef and Noodles, Broccoli Florets, Bread/Margarine and Strawberry Rhubarb Crisp for lunch. The facility menu dated Week 3 Saturday (8/23/25) documents a supper meal of Pizza burger on bun, Italian Roasted potato wedges, pineapple tidbits and milk. The facility food temperature log for meal service dated 8/23/25 documents the meal/entree temperature was 200 degrees, vegetable temperature as 200 degrees, pureed meat temperature as 200 degrees and side (potatoes/rice, noodles/dressing) dish temperature as 202 degrees. 1.R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as being dependent on staff for total assistance for eating, oral hygiene, dressing, bathing, toileting and bed mobility. This same MDS documents R1's transfer status was not attempted due to medical condition or safety concerns.On 9/6/25 at 9:10 AM V4 (R1) Power of Attorney (POA) stated on 8/23/25 R1 was served mashed potatoes that were too hot to eat. V4 stated she fed R1 a bite of his mashed potatoes and R1 spit them out stating ‘too hot.' V4 (R1) POA stated she had to cool off R1's foods for him to eat without getting burned. On 9/9/25 at 11:20 AM V25 Certified Nurse Aide (CNA) stated she was present in R1's room for the supper meal on 8/23/25. V25 CNA stated V4 (R1) POA attempted to feed R1 a bite of mashed potatoes. V25 stated ‘too hot' and spit them right back out, V25 CNA stated R1's foods were steaming as she removed the covers.2.R6's Minimum Data Set (MDS) dated [DATE] documents R6 as moderately cognitively impaired. On 9/8/25 at 12:30 PM R6 was sitting at the dining room table in the main dining area. R6 was attempting to cut through a hamburger patty on a bun. R6 was unable to cut her hamburger into smaller pieces. R6's hamburger appeared dry. R6 stated Look at that. It is just leather. R6 laid down her fork and knife while stating ‘I give up. I can't cut it.' 3.R7's Clinical admission Report dated 9/4/25 documents R7 as cognitively intact.On 9/9/25 at 8:35 AM R7 stated she had not received her breakfast meal yet this morning (9/9/25). R7 stated the meals served by the facility are bland. R7 stated the foods come ‘cool.' R7 stated the staff will warm up her meals if they have time. R7 stated there are times she has eaten the meal cold due staff not having time to warm up her meal. R7 stated I wouldn't have the chef cook my Sunday dinner. The food is awful. 4.R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact.On 9/6/25 at 1:15 PM R4 stated her lunch was ‘inedible.' R4 stated she was served a scoop of something brown as the main course. On 9/7/25 at 10:25 AM V8 Certified Dietary Manager (CDM) stated the residents should be served foods that are not only nutritious but look and taste good. V8 CDM stated she was not present on 9/6 but had heard the lunch beef and noodles did not present well. V8 CDM stated the noodles should be added in after the beef is cooked, not baked with the beef. On 9/6/25 at 11:10 AM V11 [NAME] served the lunch meal. V11 [NAME] obtained temperatures of foods served which were written on a log sheet. V11 used a large hand scoop similar to an ice cream scoop to serve portions of beef and noodles on resident plates. The beef and noodles did not have any texture, other than smooth. The beef and noodles did not change shape or move after being scooped onto resident plates. On 9/6/25 at 12:15 PM The majority of resident plates in the main dining room had the portioned-out beef and noodles still on their plates after eating. On 9/7/25 at 10:35 AM V8 Certified Dietary Manager (CDM) stated normally residents complain that the food served on the halls is not hot enough. V8 CDM stated foods should not be served if the temperature is over 190 degrees. V8 CDM stated there are multiple entries on the facility food temperature logs that were in the 190's, 200 degrees and over. V8 CDM stated Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 7 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 0804 she will educate staff to maintain foods at safe temperatures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 8 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 wear the appropriate Personal Protective Equipment (PPE) during pressure ulcer care for two (R2, R3) residents on Enhanced Barrier Precautions (EBP) out of three residents reviewed for pressure ulcers in a sample list of ten residents.Findings include:1.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 is dependent on staff for total assistance with eating, oral hygiene, dressing, bathing, toileting, bed mobility and transfers. R2's Care plan intervention dated 7/24/25 documents R2 is on Enhanced barrier precautions per Center for Disease Control (CDC) guidelines, due to presence of Supra-pubic catheter, wounds and colostomy. On 9/6/25 at 2:00 PM R2's room door did not have a sign posted for Enhanced Barrier Precautions (EBP). There were no Personal Protective Equipment (PPE) supplies outside R2's room nor were there any PPE easily accessible. On 9/7/25 at 9:30 AM R2's room door did not have a sign posted for Enhanced Barrier Precautions (EBP). There were no Personal Protective Equipment (PPE) supplies outside R2's room nor were there any PPE easily accessible.On 9/8/25 at 1:00 PM R2's room door did not have a sign posted for Enhanced Barrier Precautions (EBP). There were no Personal Protective Equipment (PPE) supplies outside R2's room nor were there any PPE easily accessible.On 9/7/25 at 1:25 pm V9 Registered Nurse (RN) and V10 Certified Nurse Aide (CNA) completed R2's Sacral Stage 4 Pressure Ulcer care. R2's room door did not have a sign posted for Enhanced Barrier Precautions (EBP). There were no Personal Protective Equipment (PPE) supplies outside R2's room nor were there any PPE easily accessible. V9 RN and V10 did not wear gowns when providing direct cares for R2.2.R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring total assistance from staff for eating, oral hygiene, dressing, bathing, toileting, personal hygiene, bed mobility and transfers. R2's Care plan intervention dated 7/24/25 documents R2 is on Enhanced barrier precautions per Center for Disease Control (CDC) guidelines, due to wound on Coccyx. On 9/7/25 at 10:00 AM V19 Licensed Practical Nurse (LPN) completed wound care for R3's Sacral pressure ulcer. R3 did not have a covering over her Sacral pressure ulcer. R3's room did have an Enhanced Barrier Precaution (EBP) sign posted on her door with Personal Protective Equipment (PPE) supplies outside of her door. V19 LPN did not wear a gown when providing direct wound care for R3. On 9/7/25 at 10:20 AM V19 LPN stated she knew R3 was on EBP and should have worn a gown for protection. V19 stated she walks in and out of resident's rooms so often, she did not think about R3 being on EBP. On 9/9/25 at 9:30 AM V2 Director of Nurses (DON) stated Enhanced Barrier Precautions (EBP) should be in place for any resident with an open wound, indwelling medical device and/or stoma site. V2 DON stated staff should have worn gowns when providing direct cares for R2 and R3 due to both residents have open pressure ulcers. The facility policy titled Enhanced Barrier Precautions Protocol revised April 8, 2024 documents Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDRO) to staff hands and clothing. If EBP is required, a sign should be placed outside the resident's room to assist in education for staff, residents, and visitors on appropriate personal protection. PPE should be used during high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing incontinence briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. Facilities Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 9 of 10 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 145772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938 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 should ensure PPE and alcohol-based hand rub are readily accessible to staff. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145772 If continuation sheet Page 10 of 10