El Paso Rehabilitation And Health Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interview and record review, the facility failed to notify a resident's family of a resident's return from the hospital for one of three residents (Resident R1), reviewed for family notification, in a sample of 5.FINDINGS INCLUDE:The facility policy, Significant Condition Change and Notification, dated 12/2024 directs staff, To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as: Transfer of the resident. Calls will be made to the resident's representative until they are reached. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given.Resident R1's electronic medical record documents Resident R1 was transferred to the local emergency room on 8/1/25 at 3:12 A.M. after experiencing increased behaviors and delusions. Resident R1'S Nursing Progress Notes, dated 8/1/25 document, 8/1/2025 (Resident R1) back from hospital at approximately 10:30 A.M., yelling and agitated and crying out, refused vitals, did report that she will run again. On 8/18/25 at 10:35 A.M., Z10/Resident R1's Family Member stated, I am (Resident R1's) guardian due to her mental health. They (facility staff) called me to tell me (Resident R1) was running away and they had called the police and were having (Resident R1) taken to the hospital. But no one ever called me to tell me (Resident R1) came back (to facility). It wasn't until I called them (facility) on (8/2/25) and asked them, did I know what had happened to (Resident R1). They (facility) are supposed to call me and let me know.On 8/19/25 at 1143 A.M., V1/Administrator verified that Resident R1's mother (Z1) had not been called by facility staff to alert her that Resident R1 had returned to the facility.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

08/19/2025

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on interview and record review, the facility failed to update a plan of care after a resident made repeated attempts, on two different days, to elope from the facility, for one of one resident (Resident R1), reviewed for care plans, in a sample of 5.FINDINGS INCLUDE:The facility policy, Care Planning, dated 12/2024 directs staff, Purpose: To address each resident's strengths, weaknesses and care needs. To use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning and wellbeing as possible. Resident R1's Nursing Progress Notes, dated 7/29/25 at 3:35 P.M. document, (Resident R1 is experiencing a change in condition. (Resident R1) left building through the front door.Resident has had no further behaviors or attempts to exit building.Resident R1's Nursing Progress Notes, dated 8/1/25 at 2:54 A.M. document,(Resident R1) was observed by CNA (Certified Nursing Assistant) walking down the hallway, and turning towards the common room. A few seconds after it was observed by nurse on camera that (Resident R1) was attempting to exit the facility. Writer, other nurse on floor, and (other staff) ran to front door as (Resident R1) was observed walking out the door and into the parking lot. (Resident R1) continued to walk forward and push past staff down the street and past the stop sign. (Resident R1) continued to walk and push forward, while yelling throughout and became violent and combative swinging closed fists at nearby staff. (Resident R1) repeatedly attempted to swing and physically assault staff. MD (Physician) was contacted and order received to send to hospital for psych (psychiatric) evaluation. Police were also then contacted as the facility staff was unable to get (Resident R1) safely back to building. (Resident R1) transported to local hospital.Resident R1's Care Plan, dated (revised) 5/27/25 includes the following Focus Area: (Resident R1) is an elopement risk/wanderer. This same plan of care includes the following Interventions: 4/10/25 Distract (Resident R1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 5/1/25 Monitor for fatigue and weight loss. 5/27/25 Calmly redirect (Resident R1) and remind her that this is her home. Find

a task, activity or simply a conversation to engage her in. No further interventions were implemented after Resident R1's elopement from the facility on 7/29/25 or 8/1/25, were developed by the facility staff. On 8/19/25 at 1:10 P.M., V10/Care Plan Coordinator verified Resident R1's care plan was not revised after Resident R1's recent attempts on 7/29/25 or 8/1/25 to leave the facility unattended. At that time, V10 stated that the facility management team should have reviewed Resident R1's plan of care after each elopement attempt and implemented new interventions to reduce the risk of Resident R1 leaving the facility.

Event ID:

Facility ID:

If continuation sheet