Inspection·January 10, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the residents' activity calendar was able to be visualized for two of two residents (R46 and R60) reviewed for accommodation of needs in a sample of 27. Residents Affected - Few Findings include: The facility's undated Resident Rights for People in Long-term Care Facilities documents You have the right to participate in your own care - Your facility must make reasonable arrangements to meet your needs and choices. 1. On 1/07/25 at 9:45am, R60 sat in a wheelchair in her room. R60 stated she is blind in her right eye. R60's activity calendar is taped on R60's bathroom door approximately five feet high. R60 stated that R60 cannot see it up there and R60 does not know what the activities are for today. R60 said I have torn it down and put it where I can see it. This writer took the calendar down and brought the calendar to R60. R60 stated I can't see that. I need bigger print. On 1/09/25, at 10:22am, R60 sat in a wheelchair in her room. R60 stated Sometimes I miss activities because I don't know what is going on. It makes me feel left out. Sometimes I like to look girlie. At this time, R60 confirmed R60 has missed the activity of nail care. R60's Minimum Data Set/MDS assessment, dated 5-10-24, documents that doing R60's favorite activities is very important to R60. R60's current face sheet documents R60 has Blindness right eye. 2. On 1/07/25, at 11:42am, R46 is in bed. R46's activity calendar is taped on R46's bathroom door approximately five feet high. R46 stated It is too high. I can't see it. R46's MDS assessment, dated 12/29/24, documents that doing R46's favorite activities is very important to R46. On 1/09/25, at 12:28pm, V2 Director of Nursing/DON asked R60 if she has been going to activities and R60 said no because R60 can't see what is going on. At this time V2 DON confirmed the activity calendar is posted up too high and is printed in a faint and small font size. V2 also confirmed that R46's activity calendar is posted too high and stated that R46 and R60 should be able to see the activities that are going on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 2 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to have the survey book up to date with the most recent survey. This failure has the potential to affect all 88 residents in the facility. Residents Affected - Many Findings include: On 1/10/25 the facility's survey book located in the front foyer area did not have the most recent survey in the book. The last survey in the book was dated 4/10/24. The facility has had complaints dated 10/5/24, 11/8/24, 11/22/24, and 12/18/24 to the State Agency that were investigated and were not in the facility's survey book. On 1/10/25 at 9:47 AM, V1 Administrator verified the last survey in their book titled Annual Health Inspections and Complaint Survey Findings was 4/10/24 and was not up to date. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 1/7/25 documents 88 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 3 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 Residents Affected - Some 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, interview and record review the facility failed to provide a home-like environment including but not limited to chipped paint, holes, missing trim, loose cable cords and unpainted walls in resident rooms for eight (R10, R11, R17, R26, R46, R59, R66, and R86) of 18 residents reviewed for environment in a sample of 27. Findings include: The facility's undated Maintenance Supervisor Job Description documents the following: Position Description: Responsible for supervising and coordinating the activities of the maintenance department to ensure environmental center compliance in accordance to Federal, State and Local ordinance, regulations and building codes. Ensures center is maintained in a sanitary, attractive, and orderly condition; in good repair, free from hazards such as those caused by electrical, plumbing, ventilation, heating and cooling systems. Principal Responsibilities: Performs all routine maintenance and repair work for the center in accordance with Federal, State and Local ordinance, regulations and building codes. Picks up work order requests daily and establishes work priority. Maintains the grounds, facility and equipment in a safe and efficient manner in accordance with current applicable federal, state and local standards. The facility was unable to provide a Maintenance Policy. 1. The facility's undated folder titled Pending Work Orders includes a Maintenance Work Order dated 8/25/24 completed by V8/Housekeeper, reporting Holes in the wall on C Hall in R26 and R10's shared room. There is no documentation confirming or addressing the work order and no dates for repair are entered. On 1/10/25 at 10:20am R26 stated there were holes in the walls in his room, indicating the wall around his roommate's (R10) bed. On 1/10/25 at 10:22am V3 Maintenance Supervisor obtained measurements of and verified there were three holes present in the walls in R26's room around R10's bed: two deeply gouged holes behind R10's headboard with one hole measuring three inches wide by three inches in height and a second hole measuring four inches wide by three inches in height. A third hole exposed and penetrated through the wallboard on the wall near the door and measured three and one-half inches wide by seven inches in height, including ripped wallboard paper and exposed plaster. 5. On 1/9/25, at 11:47am, R17 sat on the bed in his room. R17's walls have multiple areas of chipped paint and a hole alongside the wall in which R17's bed is located up against. At this time when this writer asked if the look of this wall bothers R17 and if R17 wished that it looked nicer, R17 stated, yes. The facility's undated folder titled Pending Work Orders includes a Maintenance Work Order, dated 10/19/24, which documents that R17's room has baseboard off with hole by first bed coming into room. There is no documentation confirming or addressing the work order and no dates for repair are entered. On 1/10/25, at 10:08am, V3 Maintenance Supervisor confirmed the areas of chipped paint with non-covered dry wall screws and the hole in R17's wall. At this time V3 measured the largest chipped area and the hole each at two inches by two inches. V3 confirmed that this room does not look very (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 4 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 appealing and needs a paint job. Level of Harm - Minimal harm or potential for actual harm 6. On 1/07/25, at 10:20am, R59 sat on the bed in her room. R59's walls have numerous areas of paint chipping and two cable cords dangling from the ceiling tile, one above and to the left of R59's bed, and one across from the bed. Both cable cords are hanging down approximately three feet. At this time R59 stated that R59 rests in her room a lot and that sometimes the condition of the walls bothers her. R59 stated It would make me feel better and cleaner. I don't complain as long as I am getting by. Residents Affected - Some On 1/10/25, at 10:01am, V3 Maintenance Supervisor confirmed that R59's room has two cable cords dangling from the ceiling and numerous areas of chipped paint. V3 confirmed that R59's room does not look very nice and stated that this room needs to be painted and the cable cords should be tucked up in the ceiling tiles. 7. On 1/07/25, at 10:01am, R46 was in bed. R46 stated that her room looks bad on the walls and that they (the facility) said they would put up paint, but it has been this way since R46 has been here for 10 years. R46's walls have numerous areas of chipped paint on the walls and corner trim that is cracked with parts broken off. On 1/10/25, at 10:05am, V3 Maintenance Supervisor confirmed that R46's room needs to be painted and has an area measuring one- and one-half inches by two inches that needs to be filled in and painted. V3 confirmed that the corner trim needs to be replaced. 4. During the survey conducted from 1/7/25-1/10/25, R86's bathroom door had a twelve by six inch, and three by three inch hole in the bathroom door where it was splintered and cracked in the middle of the door. On 1/10/25 at 10:25 AM, V3 Maintenance Director stated I am aware the door needs fixed, it has been needing fixed for a while, and I have a patch for it. 2. On 1/9/25 at 9:30am, noted a discolored area in R11's room on the wall next to the window. According to V3 Maintenance Supervisor, the area required sanding/smoothing and painting. This area measured three feet, four inches by seventeen inches. Another area located between the bottom of the window and above the heater/air conditioner unit had foam padding inserted and did not have dry wall or paint to cover. This area measured three feet, five inches long by two inches in height. (Noted measurements done by V3 Maintenance Supervisor.) On 1/10/25 at 10:20am, V3 Maintenance Supervisor stated that he has been the Maintenance Supervisor for the facility since August 2024 and had not noticed the areas on the wall in R11's room prior to today. 3. On 1/9/25 at 9:35am, noted a hole in the wall of R66's room on the left side of the room when facing the window. This hole measured four inches by four inches in circumference at the outer wall, tapered to one and a half inches deep within the wall, and did not go through the wall. This hole is eleven inches from the floor. (Noted measurements done by V3 Maintenance Supervisor.) On 1/10/25 at 10:25am, R66 stated, The hole has been in the wall ever since I've been in this room. (Documentation indicated R66 moved to the room on 6/6/24.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 5 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 On 1/10/25 at 10:25am, V3 Maintenance Supervisor stated that he had not been aware of the hole in the wall in R66's room. 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: 146097 If continuation sheet Page 6 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 0585 Level of Harm - Potential for minimal harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview, the facility failed to maintain the required minimum of three years of resident grievances results. This failure has the potential to affect all 88 residents residing in the facility. Residents Affected - Many Findings include: The facility's Resident Grievance Process Policy Reviewed 8/2023 documents: Copies of all grievances will be maintained per the community record retention policy. The facility's Organization and Maintenance Retention of Medical Records Dated 1/2017 documents: The retention time for medical records is seven years from discharge or the last date of service provided unless the payer for the resident was a Medicare Advantage plan, the retention period is ten years. Best practice is to retain all records, on patients of age of majority, for ten years. If the resident/patient is a minor, the record will be retained for three years after the resident/patient reaches the age of majority or seven years, whichever is longer. The facility's Grievance Binder contained resident grievances for the years 2023 and 2024. There were no grievances maintained for a third year (2022) for the required minimum of three years of grievance results. On 1/8/25 at 11:45am, V2 Director of Nursing/DON stated that the 2022 grievance reports/results were not available; stated that the facility does not have three years of resident grievances on file and stated that only the two years (2023 and 2024) and any for 2025 were available. On 1/8/25 at 3:40pm, V1 Administrator confirmed that the facility does not have resident grievances prior to 2023. V1 stated, We cannot find them and not able to provide the years of before 2023 for review. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 1/7/25 documents 88 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 7 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to develop a Care plan for Hepatitis C and Blindness for one resident (R60) of 18 residents reviewed for Comprehensive Care plans in a sample of 27. Findings include: The facility's undated Care Planning policy documents Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Purpose: 1. To assess each resident's strengths, weaknesses, and care needs. 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for reach resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible. On 1/07/25 at 9:45am, R60 sat in a wheelchair in her room. R60's right eye appears cloudy and distorted. R60 stated she is blind in her right eye. R60's current Face sheet documents R60 has diagnoses including but not limited to Unspecified Viral Hepatitis C without hepatic coma and Blindness right eye. R60's current Care plan does not include Viral Hepatitis C or Blindness to R60's right eye. On 1/10/25, at 12:49pm, V10 Care plan Coordinator confirmed that R60's current Care plan does not include Hepatitis C or Blindness right eye. V10 stated Hepatitis C and Blindness are important enough that it should be on (R60's) Care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 8 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 Based on interview and record review, the facility failed to process medication orders timely to ensure medications were given per physician order for six of 18 residents (R26, R37, R66, R72, R80, R85) reviewed for physician orders in a sample of 27 residents. Residents Affected - Some Findings include: The Medication Administration Policy for Senior Living, undated, documented all medication orders must be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records. The Medication Administration Record (MAR) should be maintained for each resident and must be up-to-date and medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and right route. 1. R26's Face Sheet documents R26 with a diagnosis of paranoid schizophrenia. R26's MAR documents on 1/8/25 Aripiprazole (an antipsychotic medication used to treat schizophrenia) 15 milligrams/mg each evening was ordered by V6. R26's MAR noted Aripiprazole was not administered on 1/8/25 or 1/9/25. 2. R37's Face Sheet documents R37 with a diagnosis of major depressive disorder. R37's MAR documents on 12/30/24 Nortriptyline (antidepressant) 10 milligrams at bedtime was ordered by V6. The MAR noted Nortriptyline 10 mg was not administered on 12/30/24 or 12/31/24. 3. R66's Face Sheet documents R66 with diagnoses of bipolar disorder and depression. R66's MAR dated 1/1/25 through 1/31/25 documents Quetiapine (an antipsychotic medication used to treat Schizophrenia) 50 milligrams at night was ordered by V6 on 12/30/24. The 12/1/24 through 12/31/24 MAR did not document V6's Quetiapine 50 milligrams order or that it was administered on 12/30/24 or 12/31/24. R66's MAR documented on 12/31/24 Escitalopram (antidepressant) 20 milligrams daily was ordered by V6. The MAR noted Escitalopram was not administered on 12/31/24. 4. R72's face sheet documents R72 with diagnoses of bipolar disorder, depression, and anxiety disorder. R72's MAR documents on 12/30/24 Trazadone 75 milligrams at bedtime was discontinued and Trazadone 150 milligrams at bedtime was ordered by V6. The MAR noted Trazadone 150 milligrams was not administered on 12/30/24 or 12/31/24. 5. R80's face sheet documents R80 with a diagnosis of generalized anxiety disorder. R80's MAR documents on 1/8/25 Lorazepam (used to treat anxiety disorders) one milligram at bedtime was ordered by V6. The MAR noted the Lorazepam was not administered on 1/8/25 or 1/9/25. 6. R85's face sheet documents R85 with a diagnosis of bipolar disorder. R85's MAR documents on 12/30/24 Quetiapine 50 mg at bedtime was ordered by V6. The MAR noted the Quetiapine 50 mg was not administered on 12/30/24 or 12/31/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 9 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 - Some On 1/9/25 at 12:25 PM, V5 (Registered Nurse) V5 stated V6 (Psychiatric Nurse Practitioner) is the only practitioner that enters her own orders into the Electronic Medical Record (EMR) and that V7 (Licensed Practical Nurse/LPN) confirms V6's orders, not the floor nurses. On 1/9/25 at 1:30 PM, V9 (Registered Nurse/RN) stated V7 (Licensed Practical Nurse/LPN) gives the nurses a typed list of residents' names and new medication orders that were entered into the EMR by V6 (Psychiatric Nurse Practitioner). V9 demonstrated the typed list of new medication ordered by V6 on 12/30/24 which was kept at the desk. V9 stated V6 and V7 conducted rounds on residents on 1/8/25 although V7 was not working on 1/9/25, therefore a list had not yet been provided to the nurses. On 1/10/24 at 9:30 AM, V7 (Licensed Practical Nurse/LPN) stated that V7 does resident rounds with V6 (Psychiatric Nurse Practitioner). V6 completes her own documentation and enters orders into the residents' electronic medical record (EMR). V6's orders will remain in a pending status until V7 confirms the order in the EMR. V7 reviewed R26, R37, R66, R72, R80, R85 MARs and stated the changes in medications were not administered as ordered. V7 stated I had an appointment yesterday and didn't get the orders (V6's orders from 1/8/25) confirmed. The nurses should know how to do that (confirm pending orders to activate the order) but I do it, so they (nurses) didn't know. V7 stated that between 1:30 PM to 3:30 PM on 12/30/24, V6 conducted resident rounds and entered orders into the residents' EMR. V7 stated she verified and completed the pending orders by 1/1/25, therefore the new medications ordered were not activated for the nurses to administer on 12/30/24 or 12/31/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 10 of 11 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 146097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738 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 0741 Level of Harm - Minimal harm or potential for actual harm Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Based on interview and record review, the facility failed to implement nonpharmacological interventions for one (R13) of eight residents reviewed for mood behavior monitoring in a sample of 27. Residents Affected - Few Findings include: Facility Behavioral Assessment, Intervention, and Monitoring Policy, dated 12/2024, documents Staff will evaluate the resident's patterns of mood and behavior; the care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice; Interventions and approaches will be based on assessment; and nonpharmacological approaches will be utilized to the extent possible to manage behavioral symptoms. R13's medical record documents R13 has the following diagnoses: Depression and Anxiety. R13's current physician orders for January 2025 document the following: Mirtazapine Oral Tablet 45 MG/milligrams give 1 tablet by mouth at bedtime related to depression; Bupropion ER/extended release oral tablet 300 MG give 1 tablet by mouth one time a day related to depression; Venlafaxine ER 150 mg capsule give 1 caplet orally one time a day related to depression; and Venlafaxine ER 75 mg capsule give 1 caplet orally one time a day related to depression. R13's current care plan has no nonpharmacological interventions identified for R13's behavior monitoring. R13's CNA/Certified Nurse Aid documentation reviewed for December 2024-January 9, 2025 (30 days) has verbal and physical behaviors documented, but no nonpharmacological interventions for R13's behavior monitoring charted. During the survey 1/7-1/10/25, V2 DON/Director of Nursing was unable to find any non-pharmacological interventions in R13's medical record. On 1/10/25 at 11:12 AM, V2 DON stated (R13) is only on antidepressants so there are no nonpharmacological interventions in place for her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 11 of 11