Inspection·November 13, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few puree solids from regular solids at that time, eventually upgraded to mechanical soft solids following ST intervention. Patient presents at assessment with mild oral and suspect mild pharyngeal dysphagia (swallowing disorder) with increased risk for aspiration/choking due to cognitive impairment. Continue puree solids and thin liquids, crush medications in applesauce. Continue supervision during oral (PO) intake due to multiple choking events.On 11/12/2025 at 09:45 AM, V1 (Administrator) stated that R1's incident date was incorrectly submitted to IDPH, and the actual incident date was 11/04/2025.R1's active orders as of 11/12/2025 showed an order for pureed diet with start date of 11/04/2025. Review of discontinued orders showed: general diet, mechanical soft texture, regular consistency that was discontinued on 11/4/2025.R1's care plan with print date of 11/12/2025 reads in part: swallowing problem related to coughing or choking during meals or swallowing med, initiated 11/05/2025. Interventions included: follow prescribed diet, monitor for signs of dysphagia, refer to speech therapist, resident to eat only with supervision, and diet changed to puree until speech therapy evaluation for safety.On 11/12/2025 at 10:17 AM, observed R1 lying in bed. R1 said she did not recall anything about the choking incident.On 11/12/2025 at 11:50 AM, V5 (CNA) said was sitting in the dining room assisting another resident with meal and R1 was seated behind her. V5 then said she heard a gurgling sound then turned around and asked R1 is she was choking; R1 nodded her head up and done. V5 added that R1's lips were dark blue and her whole face was turning blue from a lack of oxygen. V5 patted R1 on the back and lifted her arms, but nothing happened so V5 went behind R1 and gave her two upward abdominal thrusts. V5 said that R1 coughed food that looked like tiny ham chunks with some phlegm. V5 added that she was unsure of what R1's diet was at the time of incident but said the food on R1's plate looked like it was a regular diet because she had the scalloped potatoes with diced ham. V5 then said about a year ago, R1 went through the same situation and had choked on food. On 11/12/2025 at 12:03 PM, V4 (Licensed Practical Nurse) said on the day of R1's incident, a resident came up to the nurse's station and said [R1] choked. V4 indicated she went to the dining room and V5 (CNA) told her what happened. V4 added that when she approached R1, she was attempting to eat a cookie but V4 took away the cookie and brought R1 to the nursing station to assess her. V4 said when she asked R1 what happened, R1 said I couldn't get it down. V4 added that R1 has had choking/coughing issues in the past and her diet at time of incident was mechanical soft.On 11/12/2025 at 12:33 PM, V2 (Director of Nursing) said V4 (LPN) called her on day of incident and said that R1 had choked in the dining room. V2 added that she spoke with V6 (Food Service Director) who said R1 was served the correct diet but had choked on her food. Review of facility's weekly menu for week of 11/02/2025 (Sunday) provided by facility on 11/12/205 indicated the evening meal for Tuesday (11/04/2025) was crispy onion scalloped potatoes and ham, parslied carrots, bread/margarine, cookies and milk. Review of facility's dietary spreadsheet provided by V6 on 11/12/2025 dated 11/04/2025 indicated for the meal of scalloped potatoes and ham, the ham should be gnd (ground) for a mechanical soft diet. On 11/12/2025 at 1:40 PM, V6 (Food Service Director) said gnd means ground then indicated the dietary staff should be following the spreadsheets so the ham for mechanical soft diets should have been ground. V6 then indicated he was told by the dietician (V9) in the past that 1/4 inch diced ham is fine enough for the mechanical soft diets.On 11/12/2025 at 02:13 PM, V7 (Cook) said she worked on the day of R1's incident and was told by V6 since she started a few months ago that the ham is fine enough when diced for the mechanical soft diets. V7 then said she refers to the dietary spreadsheets every night and dietary staff are to follow them. On 11/13/2025 at 09:05 AM, V9 (Registered Dietician) said she didn't recall any specifics about R1 at time of interview but indicated that a resident is placed on a mechanical soft diet when they are having issues with chewing or if speech therapy made the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145476 If continuation sheet Page 2 of 3 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 145476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oregon Living and Rehabilitation Center 811 South 10th Street Oregon, IL 61061 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete recommendation. At 09:11 AM, V9 said the spreadsheets are there to be followed by dietary staff with every meal. When surveyor informed V9 of spreadsheet indicating ground ham, not diced, V9 said oh, well corporate dietitians made the recommendations to substitute diced ham for ground as an acceptable substitution because the pieces are between 1/2 inch to 1/4 inch in size and should be in the mechanical soft diet policy. V9 added that meats are either diced or ground based on the resident's tolerance but could not indicate which meat texture was tolerated by R1.On 11/13/2025 at 09:40 AM, observed in a small bowl provided by V6 (Food Service Director), several pieces of diced ham that each appeared to be the size of a green pea. V6 indicated this is the size of the ham used by the facility and is 1/4 inch by 1/4 inch in size which comes prepackaged to the facility. On 11/13/2025 at 11:30 AM, V1 (Administrator) said R1 was on a mechanical soft diet with no specifications for ground or diced meat at the time of incident. On 11/13/2025 at 12:04 PM, V10 (Speech Language Pathologist) said he did an evaluation on R1 after a recent choking incident then indicated that R1 was on a mechanical soft diet, but he was unsure of any meat texture specifications. V10 added that he reviewed R1's records and spoke with staff who reported a previous choking episode in June 2025, so his evaluation was based off nursing documentation and what he was told by staff. V10 then said he will need to further assess consistencies with R1's swallowing before making any dietary recommendations. Therapeutic Diets policy last reviewed 03/07/205 provided by facility on 11/12/2025 indicated the facility will provide a therapeutic diet that is individualized to meet the clinical needs of a resident to achieve outcomes of care. These therapeutic diets should coincide with therapeutic diets on the facility's menu extensions.mechanically altered diets will be considered therapeutic diets . The dietician and dietary manager record in the resident's medical record significant information relating to the resident's response to his or her therapeutic diet.Dental soft (Mechanical Soft) policy dated 2022 provided by facility on 11/12/2025 indicated this consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. This diet may also be used by a speech language pathologist (SLP) in the treatment of dysphagia and needs to be individualized for specific food tolerances and modified, as needed, per recommendations from the SLP. As with any diet modification, this diet should be individualized to meet the resident's needs and chewing abilities. Meat is ground or chopped into bite-sized pieces (1/2 inch or smaller) . Some communities may further differentiate the mechanical soft diet by using mechanical soft chopped meats or mechanical soft ground meats.please contact Dinning for access to these diet spreadsheets. Please consult with your SLP if your community is using a mechanical soft chopped meat or mechanical soft ground meat for dysphagia.(Policy did not indicate that diced ham is an appropriate substitute for ground ham for mechanical soft diets) Event ID: Facility ID: 145476 If continuation sheet Page 3 of 3