Odin Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Odin Health and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Nov 14, 2025

  Based on interview and record review the facility failed to notify the physician for a resident's change in condition for 1 of 3 residents (R1) reviewed for changes in condition in a sample of 13. This failure resulted in R1's hospitalization for sepsis and subsequent death.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/5/25 when the facility staff failed to notify the physician that R1 had decreased urine output and oral intake, was refusing to eat, and appeared lethargic. On 10/7/25, R1 was found to have a worsened pressure ulcer and a sharp decline in R1's overall condition and was sent to the ER (Emergency Room). R1 expired on 10/8/25 with a cause of death of Sepsis. […]

• Immediate jeopardy, isolatedF600May 15, 2024

  Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse for 3 of 3 (R2, R9, R11) residents reviewed for abuse in the sample of 34. This failure occurred on [DATE] when V4 (Physician/Co-Medical Director) asked to see and touch R9's genitalia (inappropriate word for female genitalia), while R9 was sitting in the lobby of the facility near the front doors. R9 stated this had been going on for a few months, she would get upset by V4's behavior, her anxiety would rise before he was scheduled to visit, and she began wondering if she had said something to initiate this behavior and began blaming herself. R9 stated she was afraid to tell anyone because it would be her word against his and no one would believe her. […]

• Immediate jeopardy, isolatedF689May 15, 2024

  Based on observation, interview, and record review the facility failed to ensure residents assessed as being a high risk for elopement were adequately supervised and then failed to identify this same resident as an elopement risk after an elopement for 1 of 3 (R1) residents reviewed for accidents and supervision in the sample of 34. This failure resulted in R1, who had a history of confusion and was assessed as being a high risk for elopement, exiting the facility without staff knowledge, at an unknown time, walking 4.4 miles to a neighboring town along a busy highway where he was located by facility staff at 7:00 AM on 4/13/24. The Immediate Jeopardy began on 4/13/24 when R1 exited the facility without staff knowledge. […]

• Immediate jeopardy, isolatedF760May 15, 2024

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 (R23, R10, R27) of 13 residents reviewed for medication errors in the sample of 34. This resulted in R23 experiencing a blood glucose level of 37, altered mental status and being transported by EMS (Emergency Medical Services) to the Emergency Department for evaluation and treatment. Additionally, this failure resulted in R27 experiencing anxiety and an increase in behavioral symptoms, requiring an inpatient psychiatric hospitalization . The immediate Jeopardy began on 4/9/24 when insulin was administered to R23 without first performing a blood glucose check as ordered. […]

• Immediate jeopardy, isolatedF689Apr 2, 2024

  Based on interview and record review, the facility failed to ensure residents with psychiatric diagnoses, who were at risk of elopement, were accurately assessed and appropriately supervised for 1 of 3 (R2) residents reviewed for accidents and supervision in the sample of 17. This failure resulted in R2, who has a diagnosis of schizoaffective disorder and a history of suicidal ideation's exiting the facility without staff knowledge on [DATE] sometime between 4:45 AM and 5:30 AM. R2 was located slightly more than two tenths of a mile from the facility at approximately 6:30 AM, sitting outside an abandoned building on top of a truck camper shell, in the rain. […]