Inspection·August 28, 2024

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 observation, interview and record review, the facility failed to administer oxygen therapy as prescribed and provide signage on doors where oxygen is in use for residents receiving oxygen therapy for 2 of 3 residents (R2, R3) reviewed for respiratory care in the sample of 11. Residents Affected - Few Findings include: 1. R2's Face Sheet dated 8/28/2024 documents R2 has diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Respiratory Failure. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R2's Order Audit Report dated 1/11/2024 documents, Oxygen continuous at 2 Liters/Minute per nasal cannula every shift for chest pain/SOB (shortness of breath). On 8/27/2024 at 10:20 AM, there was no oxygen in use signage located in R2's room or on R2's door regarding oxygen being utilize in this room. R2 stated she takes her portable oxygen tank to the dining room for lunch and the nurse must fill it with oxygen. On 8/27/2024 at 12:05 PM, R2 was in her room and stated she had no oxygen in her portable tank when she went to the dining room. R2 stated when she notified staff, R2 was told by an unknown staff member to try to eat as much as she could and see how she does without her oxygen. On 8/27/2024 at 1:17 PM, V10, Assistant Director of Nursing (ADON) stated R2 should have a humidification bottle on her concentrator. R2 proceeded to tell V10 about what occurred at lunch with her oxygen. R2 told V10, She (unknown staff member) couldn't do anything about it at the time, said just eat as much as you can. V10 replied to R2, Everyone should know how important oxygen is. V10 stated she would expect if a resident reports they are out of oxygen, the CNA (Certified Nursing Assistant) should notify the nurse so it could be re-filled. 2. R3's Face Sheet dated 8/28/2024 documents R3 has diagnoses of Chronic Obstructive Pulmonary Disease (COPD). R3's MDS dated [DATE] documents R3 is cognitively intact. R3's Order Audit Report dated 8/19/2024 documents, May use Oxygen at 2 Liters/Minute per nasal cannula continuously as tolerated, may titrate as needed every shift related to COPD. (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: 145585 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 145585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caseyville Nursing & Rehab Ctr 601 West Lincoln Avenue Caseyville, IL 62232 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)