Inspection·August 8, 2025

F 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow diet orders for residents who receive mechanical soft diets, failed to document residents' noncompliance with mechanically altered diets, and failed to educate facility staff on residents who are on mechanically altered diets. These failures resulted in R1, who has a history of choking and requiring the Heimlich Maneuver, being able to purchase snacks from V5 (Medical Records) that were not part of R1's physician ordered diet texture. These failures have the potential to affect all 20 residents (R1, R4 through R22) who reside in the facility that receive a mechanically altered diet.These failures resulted in an Immediate Jeopardy that began on 7/12/25. While the Immediate Jeopardy was removed on 8/08/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include: The facility Inservice Training Handout: Understanding Diet Types in Skilled Nursing Facilities (SNFs), not dated, documents, Mechanical Soft Diet (Mechanically Altered) Definition: Soft, moist foods that require minimal chewing. Meats are ground or finely chopped. No hard, crunchy, or sticky textures. Important Guidelines: Always follow speech-language pathologist recommendations. Do not serve foods outside of resident's prescribed texture level. Use visual cues, consistency checks, and documentation.The facility training policy, titled What is a texture Modified Diet, not dated, documents, Mechanically altered or soft diets is used when there are problems with chewing and swallowing. Changes the consistency of a regular diet to a softer texture. Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables. Foods to avoid on a Mechanical Soft Diet: Nuts and seeds, non-ground meats, breads with hard crust, hard candy, and raw, crunchy fruits and vegetables.R1's admission record documents R1's date of admission to the facility was 8/9/22 and his diagnoses included: Diabetes Mellitus due to underlying condition without complications, Dementia in other diseases classified elsewhere moderate with agitation, Hyperlipidemia, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without residual deficits.R1's Minimum Data Set (MDS) assessment, dated 7/1/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment.R1's progress notes dated 7/12/25 documents, RN (Registered Nurse) called to dining room with reports of Resident choking RN reported to the dining room, observed resident sitting in chair at table and taking several bites of food without swallowing between bites, color is good, V/S (vital signs) stable, afebrile, breath sounds are clear to auscultation bilaterally, SAO2 (arterial oxygen saturation) 98% (percent) on room air, resident reports I don't know why I choked this was the first time that has happened. RN completed assessment and remained with the resident to observe eating pattern and noted that resident was eating fast and taking several bites of salad without swallowing after each bite, RN encouraged resident to swallow after each bite and to follow up with a drink of water before taking additional bites, resident demonstrated appropriate swallowing. Dr. (doctor) V6 informed at 2000 (8:00pm), POA (Power of Attorney) (V7), brother notified at 2010 (8:10pm) per phone conversation, RN contacted (Contracted Diagnostic Company) services for STAT (immediate) chest X-Ray, spoke with (Contracted Diagnostic Company) staff, STAT chest X-Ray ordered. Facility manager on duty, V3 (Assistant Director of Nursing/ADON) notified.On 8/5/25 at 10:30am, V8 (Certified Nursing Assistant/CNA) stated, I was serving the supper meal in the dining room when I heard another resident yell 'He's choking.' I immediately went to R1 and saw that he was unable to breathe so I got him (R1) to stand up and performed the Heimlich Maneuver on him. It took approximately four good thrusts before a small piece of food was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 2 of 6 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 08/08/2025 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some dislodged and he started coughing so I stepped back and let him continue and he was able to cough up the rest of the lettuce up by himself (R1) and began breathing and talking. After I knew he (R1) was ok I went and got his nurse who completed an assessment on him.R1's facility SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note dated 7/12/25, documents, resident (R1) had a swallowing issue.R1's Physician Orders dated 7/14/25 document that R1's diet was changed to CCD (Controlled Carb Diet) diet Mechanical Soft texture, Regular/Thin consistency, no lettuce, or green leafy vegetables for diet related to Diabetes Mellitus due to underlying condition without complications.R1's current care plan documents, (R1) is a risk for aspiration and choking related to impaired swallowing function evidenced by actual choking incident requiring Heimlich Maneuver and (R1) requires a modified diet (mechanical soft) with thin liquids.R1's Incident Report for Choking/Emergency Intervention dated 7/12/25, documents at approximately 6:45pm R1 choked requiring the Heimlich Maneuver, R1 was assessed post choking, chest X-Ray was ordered, R1 monitored every four hours for 72 hours for respiratory changes, a repeat chest X-Ray to be done 72 hours after initial chest X-Ray, diet temporarily downgraded to mechanical soft pending Speech Therapy evaluation, Speech Therapy referral for evaluation initiated, R1 to be supervised at all meals, R1's Care plan updated, entered on facility Risk Management log and POA (Power of Attorney) notified.On 8/1/25 at 11:50am, R1 noted to purchase a can of potato chips, chocolate wafer bar and a candy bar from V5 (Medical Records) at the snack room. R1 stated he does not have a swallowing issue and does not remember choking or getting the Heimlich maneuver a couple of weeks ago.On 8/1/25 at 12:00pm, V4 (Dietary Manager) stated, If someone is on a Mechanical Soft Diet, they definitely should not be eating potato chips. However, we cannot deny someone something if they want to eat it, we can only educate them.On 8/1/25 at 12:10pm, V1 (Administrator) stated, It's a double edge [NAME]. Residents have the right to refuse orders and we can't keep them from buying snacks from vending. That would be impossible to supervise. All we can do is educate when we see them not following dietary orders.R1's progress notes dated 7/17/25 at 5:17pm, documents, Resident was noted in the dining room eating flaming hot (brand name of type of chip) that he purchased from another resident. Resident was educated that he is a mechanical soft diet and that he should not be eating those at this time d/t (due to) risk of choking. Resident was reminded of choking incident and why his diet has been modified. Resident refused to stop eating Cheetos but was supervised while eating and had no issues during this time. MD (Medical Doctor) notified. No further documentation noted in R1's medical record regarding education on diet.On 8/1/25 at 1:40pm, V3 (Assistant Director of Nursing/ADON) stated, We do not have vending machines. We have a staff member who opens a snack room for a period of time during the day so the residents can buy snacks.On 8/5/25 at 10:20am, V7 (R1's Power of Attorney) stated, I'm not recalling them calling me to notify me of (R1) choking and requiring the Heimlich Maneuver. They haven't called me about buying snacks that are hazardous either. They have called me recently about fights he (R1) has and suggestions on looking at places closer to me with a dementia unit but nothing about him (R1) choking, his diet or needing to see Speech. I have my faculties about me, and I would remember a call like that. V7 also stated that he would be willing to come to the facility if needed to get the Speech evaluation done if the facility would give him prior notice to get there. V7 stated, Ultimately I want him to be safe so whatever is in his best interest I'm willing to do.On 8/5/25 at 10:35am, V6 (Medical Director/Physician) stated, I had been made aware of his (R1) choking episode, but the facility has not contacted me about his (R1) noncompliance with following his down-graded diet or to speak with him (R1) or his family to go over the risk of not following the prescribed diet. It would be futile to attempt to educate him (R1) on the risk of not following his diet due to his poor cognition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 3 of 6 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 08/08/2025 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some he (R1) would forget within an hour anything I've told him. The staff should provide him with safe food options in accordance with his diet but I'm not sure how they will be able to manage that with his (R1) cognitive impairments.On 8/5/25 at 10:50am, V5 (Medical Records) stated, I am in charge of opening the snack room so residents can buy snacks. I have been given no guidance on resident diets up until last Friday (8/1/25) when I was told that I let a resident (R1) purchase chips and he was not supposed to have them but prior to that they have said nothing to me about resident diets. I'm familiar with therapeutic diet consistencies like Mechanical Soft or Pureed but I have no clue what residents in this building are receiving those types of diets. V5 also stated that he opens the snack room from 11am-1pm on Monday, Wednesday, and Fridays and 12-1 on the other days typically.R1's Speech Therapy Evaluation dated 8/4/25, documents, The ST (Speech Therapist) discussed with the DON (Director of Nursing) and the dietary manager about continuing to provide mechanical soft solids, and thin liquids, as tolerated. Cut up solids prior to placement on the table and try placing solids in individual bowls to assist with reduced rate of intake. ST also encouraged the staff to remind the patient at each meal to slow down and take sips of liquids every 2-3 (two-three) bites.On 8/5/25 V10 (Certified Nursing Assistant/CNA), V11 (Licensed Practical Nurse/LPN), and V12 (Registered Nurse/RN) all stated that they had just received in-servicing on R1's diet.On 8/6/25 at 11:20am, V14 (Speech Therapist) stated, I evaluated (R1) this past Monday for swallowing concerns due to his recent choking. He (R1) was downgraded by the facility and his (R1's) physician to a Mechanical Soft diet. He (R1) was not very receptive about my recommendations while watching him eat, he (R1) ate extremely fast and is very impulsive. Potato chips would not be part of a Mechanical Soft diet. If he (R1) were to get a bag of potato chips from a vending machine and eat them unsupervised there is a potential for him to choke, aspirate, or even die from choking because of the way he eats.On 8/6/25 at 11:30am, V12 (Registered Nurse/RN) stated, I don't have all my residents' diets memorized, so no I would not know if they were eating what they shouldn't be without going to look at their orders and unless they were having issues when I saw them snacking, I wouldn't question their diet.On 8/6/25 at 11:45am, V17 (Certified Nursing Assistant/CNA) stated, I do not know everyone that receives a Mechanical Soft diet, but I do know a few. I also know that they should not be eating anything hard.On 8/6/25 at 2:19pm, V18 (Registered Nurse/RN) reports that the vending room causes problems because the residents buy whatever they want.2. R4's admission record documents R4's date of admission to the facility was 2/24/20 and his diagnoses included: Diabetes Mellitus due to underlying condition with Diabetic Autonomic (Poly)Neuropathy, Type 2 Diabetes Mellitus without Complications, Magnesium Deficiency, Hyperlipidemia, Gastro-Esophageal Reflux Disease without Esophagitis, Heartburn and Constipation.R4's Minimum Data Set (MDS) assessment, dated 7/1/25, documents R4 has a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition is intact.R4's Physician Orders dated 2/4/25, documents R4 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 11:20am, R4 observed in his room with bag of chips, bag of cheese curls, and a chocolate candy bar on his bed. R4 reports that staff do not tell him what snacks he shouldn't purchase due to diet restrictions.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R4's current care plans lacked non-compliance with diet textures prior to 8/7/25.3. R5's admission record documents R5's date of admission to the facility was 7/26/22 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Hyperkalemia, Deficiency of other specified B Group Vitamins, Hyperlipidemia, and Gastro-Esophageal Reflux Disease without Esophagitis.R5's Minimum Data Set (MDS) assessment, dated 7/2/25, documents R5 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact.R5's Physician Orders dated 2/4/25, documents R5 has an order for Regular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 4 of 6 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 08/08/2025 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 11:16am, R5 observed sitting in his room with 2 cans of potato chips, 2 Chocolate candy bars, 2 bottles of soda unopened in front of him on bedside table. R5 states that he does purchase items from the vending room, and he usually gets cans of chips, candy bars, and soda. R5 stated that staff do not advise him on what he should not purchase or any risk to eating what I buy.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R5's current care plans lacked non-compliance with diet textures prior to 8/7/25.4. R9's admission record documents R9's date of admission to the facility was 2/10/21 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Hyperkalemia, Deficiency of other specified B Group Vitamins, Hyperlipidemia, and Gastro-Esophageal Reflux Disease without Esophagitis.R9's Minimum Data Set (MDS) assessment, dated 6/9/25, documents R9 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact.R9's Physician Orders dated 3/5/25, documents R9 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency, supervision for all meals.On 8/6/25 at 11:30am, R9 observed lying in bed with head elevated. R9 reports that he purchases popcorn and drinks from the vending room. R9 stated, They tell me I shouldn't have popcorn, but it is my life, and I am going to live it.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R9's current care plans lacked non-compliance with diet textures prior to 8/7/25.5. R12's admission record documents R12's date of admission to the facility was5/1/04 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Dysphagia Oropharyngeal Phase, Unspecified Dementia Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance. Mood Disturbance, or Anxiety, and Constipation.R12's Minimum Data Set (MDS) assessment, dated 6/24/25, documents R12 has a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition is intact.R12's Physician Orders dated 3/5/25, documents R12 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 1:42pm, R12 reports that he purchases food items from the vending room, but staff do not advise him on what food items to avoid because of dietary restrictions.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R12's current care plans lacked non-compliance with diet textures prior to 8/7/25. V1 (Administrator) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy on 8/7/25 at 1:58pm.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R1 has remained free from any harm or poor outcomes since incident on 7/12/2025 through current date 8/7/20252. On 8/6/25 V1/Administrator completed educated 1:1 with V5 (Medical Records) on Modified Diets and Resident Rights 3. On 8/6/25 Education for all staff on Modified Diets and Resident Rights completed by Administrator/V1 and IDT (Interdisciplinary Team). 4. On 8/6/25 AD HOC QAPI/Quality Assurance and Performance Improvement meeting held by members of QA/Quality Assurance Team and noted opportunities for improvement and process changes. 5. On 8/6/25 the facility updated process on Vending: Staff members perform vending to obtain a current list of resident diets. Staff to encourage residents to obtain items that align with ordered diet. If a resident should use their right to choose items outside of modified diet, nurse to be alerted and resident to be educated, physician notified if necessary, and resident to be encouraged to consume said items in common area in staff visual to monitor for safety. 6. On 8/6/25 Administrator/V1 educated 1:1 with V5 on facility updated procedure for vending cart in relation to modified diet. 7. On 8/6/25 Education completed with other staff on updated procedure for vending cart in relation to modified diet staff completed by V1/Administrator and IDT. 8. On 86/25 reviewed current plan of care of R1 with V6/Medical Director. Consideration for resident physical, chronic mental health concerns, and well as resident rights and quality of life/preferred preferences reviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146097 If continuation sheet Page 5 of 6 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 08/08/2025 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete New orders received, responsible party made aware, and plan of care updated by V22/Care Plan Coordinator. 9. On 8/7/25 staff educated on plan of care changes by V1/Administrator and other IDT members completed. 10. On 8/6/25 staff educated by V13/Director of Nursing/DON and other IDT members on Electronic Medical Record and ease of noting current diet order in resident profile. 11. V1/Administrator or V13/DON to educate staff monthly on Modified Diets and Resident Rights and updated vending cart procedure through next QAPI review to assure understanding. 12. IDT to review all residents with modified diets to assure resident adherence to diet. If residents noted to utilize the right to choose or right to refuse and have noted to deviate from prescribed diet, IDT to assure education, notification to parties if applicable, and Refusal of Treatment consent and documentation if applicable, and updated plan of care. Event ID: Facility ID: 146097 If continuation sheet Page 6 of 6