Health inspection·March 20, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide oxygen therapy as ordered for 1 of 3 residents (R2) reviewed for respiratory care in the sample of 4. Residents Affected - Few Findings include: 1. R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and chronic respiratory failure with hypoxia. On 3/19/25 at 8:34 AM, R2 stated the power went out on 3/14/25 and she had to go without oxygen for a couple of hours. She stated she begged for portable oxygen, but they never brought it. She was starting to feel a little short of breath before the power kicked back on. R2's 8/26/24 Physician Order documents if resident complains of or has signs and symptoms of shortness of breath when lying flat, ensure the head of bed is elevated and/or assist her with propping up pillows when in bed (except while providing care) at every shift. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, dependent with bed mobility and transfer, and received oxygen therapy. R2's Care Plan revised 1/16/24 documents R2 is at risk for impaired oxygenation, weakness, shortness of breath, fatigue, skin pallor (paleness), lightheadedness, dizziness and a fast heartbeat related to diagnosis of COPD and OSA. R2's March 2025 Medication Administration Record (MAR) documents blanks in the rows labeled SOB (Short of Breath) (Yes or No) and Administered for the evening shift on 3/14/25. R2's 10/2/24 Physician Order documents oxygen at 2 liters/minute per nasal cannula continuously and as needed while in bed for chest pain/shortness of breath. R2's March 2025 MAR does not document oxygen was provided on evening shift on 3/14/25. On 3/19/25 at 10:15 AM, V6, Registered Nurse (RN), stated R2 only uses oxygen as needed. On 3/19/25 at 3:05 PM, V9, Nurse Practitioner (NP), stated R2 is cognitively intact and is able to determine when she needs supplemental oxygen. (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: 145581 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 145581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206 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)