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 (continued on next page) 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 Page 1 of 2 Event ID: 145431 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 145431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530 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)