Odin Health And Rehab Center

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

consciousness. The Immediate Jeopardy that began on 10/5/25 was removed on 10/30/25 when the facility took the following actions to remove the immediacy and correct the deficient practice:1. A full house review of all residents with wounds was conducted and was completed by V2, Director of Nurses, on 10/30/25, to verify current wound status and ensure any noted decline was promptly communicated to the physician.2.

On 10/30/25, V2 conducted a 72-hour audit of all residents for change in condition. This audit included a

review of Nurses Notes, Progress Notes, and Alert Charting for the 72-hour period prior completed by V2 and V5.3. A full-house review of all residents was completed by V3 and V5 on 10/30/25, to verify current wound status and ensure any noted decline was promptly communicated to the physician. Any discrepancies identified were immediately corrected through direct physician notification and documentation updates.4. On 10/30/25, all licensed nursing staff received education by V2 and V5 on the requirements at F-F580, emphasizing timely physician and responsible party notifications for any change in condition, abnormal labs/vitals, new or worsening wounds, decreased urine output/fluid intake, and functional decline, and appropriate documentation of same. Certified Nursing Assistants (CNAs) were re-educated to immediately report any observed changes in condition to the charge nurse by: V2 (Completed 10-30-25).5. On 10/30/25, V22, Corporate Nurse, and V22, Corporate Chief Operating Officer, reviewed the facility's Physician Notification and Change in Condition Policies, with no changes made.6. V2 will conduct the following ongoing monitoring activities:a. Conduct daily reviews of the Nursing 24 Hour Report for 8 weeks to verify timely and accurate physician/responsible party notifications.b. Review a minimum of three (3) random resident charts weekly for eight (8) weeks to confirm compliance with F-F580 documentation standards.c. Immediately correct and reeducate any staff involved in identified discrepancies.d. Present audit findings and corrective actions during weekly Quality Assurance /Interdisciplinary Team Meetings.e. Provide ad hoc education and reinforcement as indicated.7. V1, Administrator, will conduct the following ongoing monitoring activities:a. Validate and monitor V2's audit outcomes weekly to ensure continued compliance for 8 weeks.b. Conduct monthly Inservice education for all nursing staff on F-F580 notification standards and documentation requirements for a period of 3 consecutive months.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

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 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

mentioning in the facility's nursing staff group chat, date unknown, that the wound had odor and probably needed to have the treatment changed. V18 stated all nursing staff including administrative nursing staff are tagged in this chat. Nobody reported to V18 that Resident R1 was feeling warm, and V18 does not think Resident R1's vitals were checked. V18 stated there was nothing in Resident R1's presentation that she felt she needed to call her Physician about.On 11/6/25 at 10:20am V17, CNA, stated she worked with Resident R1 from 6pm to 6am on 10/5/25. V17 stated Resident R1 looked, Tired, sick and lethargic and maybe dehydrated. V17 stated she recalled seeing a clean dry dressing to the sacral area. V17 stated she does not recall any areas to the heels. V17 stated the sacral wound, Had an odor to it, you couldn't smell it at her door but you could smell it at the bedside. V17 stated she did not specifically recall informing the nurse about the odor.2. Resident R3's Face Sheet documented an admission date of 9/29/25 and listed diagnoses including Chronic Obstructive Pulmonary Disease, Arteriosclerotic Heart Disease, Cervical Spinal Fusion, and Hypertension. Resident R3's Minimum Data Set, dated [DATE REDACTED] documented that Resident R3 has no deficits in cognition and is dependent on staff for transfers and toileting.The November 2025 Wound Log documented Resident R3 had a deep tissue injury to the left heel with

an onset date of 9/9/25.Resident R3's Care Plan dated 10/7/25 documented a problem area, Impaired skin integrity as evidenced by area left heel, with a corresponding intervention, Treatments per physicians orders.Resident R3's Physicians Orders documented a 10/22/25 order, Cleanse Left heel wound with normal saline or wound cleanser, pat dry, apply mix of silver sulfadiazine cream, hydrogel, and collagen powder, secure with dry dressing every day shift.Resident R3's Treatment Administration Record (TAR) for October 2025 showed no documentation that this treatment was done from 10/22/25 to 10/31/25.Resident R3's November 2025 TAR showed no documentation that this treatment was done on 11/1/25 through 11/3/25.On 10/31/25 at 9:35am, V3 was observed providing wound care as ordered to Resident R3's left heel, which was noted to have a non-open deep tissue injury.On 11/13/25 at 11am, V3 stated he does the wound care treatments Monday through Friday, and floor nurses are responsible for doing them on the weekends. V3 stated he generally does all the treatments and goes back and documents them at the end of the day. V3 stated he must have forgotten to document Resident R3's wound care treatments. When asked if the treatment was being done on weekends, V3 stated he is not sure.A Pressure Ulcer Policy dated 8/31/23 documented, Purpose: To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. It is

the responsibility of the Charge Nurse/Designee to care for pressure areas, and provide treatments as ordered. It is the responsibility of the Charge Nurse/Designee to measure and document the pressure areas weekly. It is the responsibility of the Charge Nurse/Designee to monitor for healing progress, and ensure appropriate treatments are in use. It is recommended that the DON/Designee make frequent pressure ulcer rounds with the Charge Nurse. It is the responsibility of the CNAs to report any skin conditions to the Charge Nurse immediately upon identification. 5. The physician is to be notified when, A.

Pressure ulcer develops, B. When there is a noted lack of improvement after a reasonable amount of time, and C. Upon signs of deterioration. 7. Documentation of the pressure ulcer must occur upon identification and at least once a week and as needed until healed. Assessment is to include C. Treatment and response to treatment, and E. Update physician and residents POA of any regression of wound.

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