Inspection·February 6, 2025

F 0695 suction wasn't done properly. On 1/27/25, R1's roommate said that R1 was struggling for almost an hour and thirty minutes, and nobody made rounds or cared for him. Level of Harm - Actual harm Residents Affected - Few On 2/5/25 at 1:35 PM, V4 (Fire Department Lieutenant) stated, When we got there, no staff was present in R1's room. It was just R1 and his roommate. R1 was in poor condition with respiratory distress. The nurse told us that R1 had difficulty breathing for five minutes, but the roommate said R1 had been struggling to breathe for an hour to an hour and thirty minutes. We suctioned R1 and a significant amount of secretions came out. His oxygen saturation improved from the low 70s to the mid-90s. I did not see a mucus plug, but I heard from colleagues verbalizing it. On 2/5/25 at 12:00 PM, V5 (Fire Department Crew) stated that R1 was in respiratory distress when he arrived. R1 had been struggling so long that he looked tired of breathing. V5 continued that he didn't think the nurse had suctioned his trach and mouth, and she wasn't even there in R1's room when his team arrived. V5 also stated that the facility seemed disorganized, and V5 and his team suctioned R1's trach; a good amount of secretion came out. As soon as they suctioned him, he was much improved, and a mucus plug came out when they suctioned R1 in the ambulance. V5 added that R1's oxygen saturation improved from below 80 to over 95%, and R1's skin color returned to normal. On 2/5/25 at 1:10 PM, V6 (Fire Department Crew) stated, The nurse (V11) was not even in his room. R1 had a very difficult time breathing, and his right leg was hanging on the right side of his bed. His oxygen saturation was only mid-70s. He was breathing through the mouth; his trach was occluded. There were blood-tangled secretions on his pillow, and his trach mask was not connected to the oxygen tubing; it was disconnected. The nurse didn't mention anything about whether she had suctioned R1 or not. She said R1 had breathing difficulty for 5 minutes, and she left after handing over the paperwork. R1 roommate told my colleagues that R1 had been struggling to breathe for 60-90 minutes. On 2/5/25 at 2:45 PM, V9 (Nurse Practitioner/NP) stated, R1 has been on trach, ventilated, and had respiratory issues. He requires mouth and trach suction. Staff should suction as needed. If a trach resident is having breathing difficulties and oxygen is below 90, I would expect staff to suction his trach and mouth and call 911, as he is in respiratory distress. On 2/4/25 at 1:05 PM, V2 (Director of Nursing/DON) stated that R1 was producing a lot of secretions, and they had suction set up at the bedside to suction him. V2 continued that on 1/26/25, at midnight, an agency nurse (V11) took over R1's care, and a couple of hours later, V11 called my ADON (Assistant Director of Nursing) and called 911 due to R1 being tachycardic and using accessory muscles to breathe. V2 added that she didn't have any documentation proving that V11 suctioned R1 while he struggled to breathe. The order was to suction as needed. On 2/5/25 at 11:50 AM, V2 also stated that if she sees a resident with a trach is having breathing difficulties and if oxygen is below 90%, she will suction him to improve his oxygen level. R2 (R1's roommate on 1/26/25) is a [AGE] year-old male admitted on [DATE] with cognition intact as per the MDS dated [DATE]. On 2/4/25 at 12:30 PM, R2 stated, R1 was his roommate on 1/26/24 when he transferred to the hospital. R1 was gaging and choking that night. Sometimes they suction him, and sometimes they don't. The afternoon shift nurse (V10) tried to suction him. He was coughing with bloody sputum. The night nurse was from an agency, and she was not qualified to suction R1. She called 911. R1 might have had that breathing difficulty for 30-90 minutes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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 0695 Level of Harm - Actual harm Residents Affected - Few On 2/5/25 at 10:00 AM, R2 added, When R1 was having breathing difficulty on 1/27/25 in the early morning, the CNA (V8) called the nurse (V11), and she came in, and I don't remember if V11 suctioned R1. R1 was making some specific unusual sounds with a mouthful of phlegm. The night nurse (V11) was from the agency. R1 was suctioned during the previous shift by V10. V11 told the EMS (Emergency Medical Service) that R1 had breathing difficulty for 10 minutes. But he had that difficulty for 30-60 minutes. A review of R1's care plan documents that R1 was care planned for shortness of breath related to respiratory failure, with interventions including maintaining a clear airway by encouraging the resident to clear their own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear them. The facility provided Tracheotomy Care policy (revised June 2005) document: Provide tracheotomy care as often as needed, at least once per shift, and PRN. On 2/5/25 at 10:40 AM, V13 (Ombudsman) stated that she receives many complaints from residents. The fire department called her and reported that the facility was not suctioning R1, causing severe respiratory distress and hospitalization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 3 of 3