Health inspection·April 26, 2024

F 0684 Level of Harm - Actual harm Residents Affected - Few potential for respiratory difficulty secondary to diagnosis of chronic obstructive pulmonary disease. Unable to lie flat due to shortness of breath. Administer oxygen per MD orders. Monitor for signs of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence. R2 requires oxygen therapy secondary to respiratory failure and chronic obstructive pulmonary disease. Adjust oxygen to maintain saturation within adequate parameters (no parameters given). Administer oxygen per MD orders. Monitor for changes in respiratory status. Report any acute changes to MD. Monitor for signs and symptoms of respiratory distress and report to MD as needed. Respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. The Nurse's Notes, dated 3/15/24 for R2 showed, at 12:55 AM, receiving oxygen at 3 liters per nasal cannula; head of bed elevated to prevent shortness of breath. At 6:34 AM resident was diagnosed with pneumonia on 3/14/24 by chest x-ray. Resident was started on levofloxacin 500 mg per day and received the first dose last night. Resident on 3 liters oxygen continuously by nasal cannula. Resident oxygen saturations monitored at 2:30 AM and (oxygen) saturation was 93% on 3 liters; upon next round at 4:00 AM resident saturation was 88% and resident was given breathing treatment. Resident's head was lowered to change her adult brief and resident's saturation dropped to 77%. Resident oxygen temporarily increased to 5 liters and oxygen saturation increased back up to 88%. There was not a complete assessment documented or notification to the doctor of a change in condition when R2's oxygen saturations started to drop, continued to stay lower than normal, and oxygen was increased to 5 liters. The Resident's Vitals Record for R2, dated 3/15/24, showed at 2:29 AM, her oxygen saturation was 93% (no liters of oxygen documented). At 6:05 AM, R2 was 88 % on 5 liters of oxygen per nasal cannula. At 8:34 AM, R2's oxygen saturation was 84% (no liters of oxygen documented). The Change in Condition Evaluation form completed and dated 3/15/24 at 8:32 AM (4.5 hours after her initial change in condion) showed, Respiratory evaluation - other respiratory changes. Specify other: pneumonia. The assessment did not include if there was shortness of breath present or lung sounds. The Transfer Form completed by V12, RN (Registered Nurse), and dated 3/15/24 at 8:38 AM for R2 showed R2 was sent to the hospital on 3/15/24 at 8:25 AM for respiratory arrest. Pulse 102, respirations 20, oxygen saturation 84% via nasal cannula. Devices/treatments: oxygen at 6 liters per minute by nasal cannula/mask. The Nurse's Note written by V12, RN, and dated 3/15/24 at 1:53 PM for R2 showed resident oxygen saturation dropped to the low 80's while on 6 liters of oxygen with a continuous pulse oximeter on. R2 was sent to the emergency room. The Emergency Department Provider Note, dated 3/15/24 for R2 showed, (R2) .presents with altered mental status. The patient currently resides at a nursing home. The paramedics state the patient was noted to be altered over the past two days. The patient was noted to be hypoxic on room air today. As such, she has been transferred to the ED (emergency department) for evaluation. On arrival to the ED, the patient was in severe respiratory distress, with altered mental status, and unable to provide a medical history. Physical exam: blood pressure 143/46; pulse 124; temperature 102.7 degrees Fahrenheit; respiratory rate 38. Pulmonary: tachypnea, accessory muscle usage and respiratory distress present. Decreased breath sounds present. Neurological: she is unresponsive. Medical decision-making: On arrival the patient was unresponsive, hypoxic and in respiratory failure. As such, the patient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145259 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 145259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Park Strathmoor 5668 Strathmoor Drive Rockford, IL 61107 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 0684 was emergently intubated. Level of Harm - Actual harm On 4/26/24 at 11:57 AM, V13, RN, stated shortly before R2 went to the hospital, her oxygen saturation dropped some, so he bumped her up while he tried to contact the doctor. V13 stated R2 was maintaining her oxygen saturation in range, his shift ended, and another nurse came in. V13 stated if R2's baseline oxygen stauration was in the mid 90's on 3-4 liters and she dropped to 88%, that would be a change in condition for the resident. V13 stated he would have called the doctor. V13 stated he normally documents he contacted the doctor or that the doctor was contacted. V13 stated R2 was alert and talking to him. Residents Affected - Few On 4/26/24 at 11:37 AM, V12, RN, stated she received report at 6:00 AM on 3/15/24 from V13, RN, who told her R2 had been diagnosed with pneumonia and was maintaining her oxygen saturation. V12 stated V13 told her he bumped up R2's oxygen to maintain her oxygen saturation at 88%. V12 stated V13 said he had put a continuous pulse oximeter on R2 because she had been de-satting (oxygen saturation level was dropping). V12 stated R2 de-satted quickly later. V12 stated after she spoke to the doctor, she put R2 on 6 liters. V12 stated she was told by the physician to send R2 out. V12 stated they have to follow the phsycians orders for oxygen. V12 was not sure if having an oxygen saturation of 88%-92% for somone with chronic obstructive pulmonary disease was in the policy or not. V12 stated she did not remember if she wrote the order from the doctor to increase R2's oxygen to 6 liters or not. On 4/26/24 at 12:20 PM, V11, NP (Pulmonology Nurse Practitioner), stated R2's baseline oxygen saturation was 93% - 96% on 3 liters of oxygen. V11 stated R2 's oxygen saturation of 88% on 5 liters of oxygen would be a change in condition for her, and the provider should be updated. V11 stated if the nurse could not titrate the oxygen back down and go to R2's basline oxygen saturation, that should be relayed to the provider. If R2 needed more oxygen and was at 6 liters then R2 needed to be sent out; she was unstable. V11 stated if they knew R2 had severe chronic obstructive pulmonary disease, had pneumonia, and needed an increase in oxygen, then the provider should have been notified right away On 4/26/24 at 1:54 PM, V15, CNA (Certified Nursing Assistant), stated R2 was not her resident on the day she was sent out, but she helped the other CNA with her. R2 was breathing heavily, had her oxygen on, and a full oxygen tank next to her that was working. V15 stated they reported it to the nurse. On 4/26/24 at 1:59 PM, V16, CNA, stated R2 had continuous oxygen. R2's oxygen saturation was unstable and it started at night and was lower than it should have been. When (R2's) oxygen saturation monitor beeped, I got the nurse. (R2's) pulse oximetry was on the lower end before I came in. (R2) wasn't speaking; she mumbled, but it wasn't clear. (R2's) breathing did not sound right. (R2) sounded more congested, a heavier sound. V16 stated R2's oxygen was at 5 liters before the pulse oximeter machine started alarming The facility's Oxygen Titration policy (9/2020) showed, oxygen will be titrated to maintain oxygen saturation levels greater than or equal to 92% unless prescribed otherwise. The facility's Change of Condition (Resident) policy (9/2020) showed, attending physicians or physician on call/NP (nurse practitioner) and responsible party will be notified of all changes in condition. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145259 If continuation sheet Page 3 of 3