Health inspection·March 26, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow its policy for Oxygen Administration to ensure that oxygen was available for one (R1) resident of three residents reviewed for oxygen saturation in the sample of three. Residents Affected - Few Findings include: Facility's Oxygen Administration Policy dated 2/10/25, documents: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. R1's current Care Plan documents: (R1) has altered respiratory status/difficulty breathing related to Chronic Obstructive Pulmonary Disease/COPD, unspecified. Intervention: Oxygen at 6 Liters per minute Via Nasal Cannula; Goal To Maintain 02/oxygen saturation greater than 90 percent. R1's Diagnoses include: Acute and chronic respiratory failure with hypoxia; Chronic Obstructive Pulmonary Disease/COPD, Unspecified dementia, anxiety. R1's Hospital Notes dated 3/5/25 documents: Diagnosis Hypoxia; reason for visit shortness of breath. R1's Physician Orders include: Every shift ensure resident has (oxygen) on. On 3/26/25 at 9:55am, V2 Director of Nursing/DON stated that CNAs can check oxygen tanks; stated that when R1 was sent to Emergency Department/ED on 3/5/25, that no one had checked R1's oxygen tank when R1 went down to Activities prior to being sent out. At this time V2 stated: (V10 Registered Nurse/RN) told me that she got the (portable oxygen tank), put it on R1's wheelchair and put the nasal cannula in R1's nose; that she did not check to see if the tank was full. The Activity Director (V7) came to get R1 after breakfast, Activity was an hour. (V10) went to get R1 from Activities and realized the portable was empty; it was light. She took R1's 02 (oxygen saturation) and it was 64%--never went up higher than that. (R1) was sent to the ED. On 3/26/25 at 11:10am, V10 Registered Nurse/RN stated that on 3/5/25, R1 was in Activities and V10 checked on R1; stated that she did not know who took R1 down to Activities and was not sure if R1's Page 1 of 2 145431 145431 03/26/2025 Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few portable oxygen tank was checked. Stated that in Activities, she checked R1's tank and it was empty; that when she checked R1's oxygen saturation, it was lower than her base. V10 stated, I did not know (R1's) tank was empty until I checked it when she was at Activities. On 3/26/25 at 10:52am, V11 Licensed Practical Nurse/LPN stated that during her morning rounds, she checks R1's oxygen level to make sure it is okay as it drops below her base (90 to 95) at times when R1 is sleeping. V11 stated, I like to keep an eye on (R1) because her oxygen saturation went to 85 at one time. She has issues with breathing and has COPD (Chronic Obstructive Pulmonary Disease). On 3/26/25 at 1:30pm, V2 DON stated: Ultimately the nurse should make sure oxygen is on and it (portable tank) is filled; responsibility is the nurses to make sure the oxygen is on, tank is filled and make sure the resident has oxygen. 145431 Page 2 of 2