Health inspection·April 23, 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 observation, interviews and record review the facility failed to ensure that two residents (R5 and R6) that receive supplemental oxygen in the facility had active Doctor's orders. This failure has the potential to affect 31 residents currently receiving oxygen in the facility. Residents Affected - Few Findings include: R5 is [AGE] year old with diagnosis including but not limited to: chronic obstructive pulmonary disease, morbid obesity, anemia, congestive heart failure and nicotine dependence. R5 has a BIMS of 15, which indicates cognitively intact. R6 is [AGE] year old with diagnosis including but not limited to: chronic obstructive pulmonary disease, malignant neoplasm of unspecified part of left bronchus or lung, malignant neoplasm of upper respiratory tract, angina pectoris and muscle wasting. R6 has a BIMs of 14, which indicates cognitively intact. During investigation on 4/22/2025 at 12:05 PM, R6 was observed in bed receiving supplemental oxygen (O2) via nasal cannula at 4 LPM (Liters per minute). R6 stated that he had been receiving oxygen in the facility since his admission on [DATE]. Surveyor inquired about R6's O2 order. On 4/22/25 at 12:11 PM, V5 (LPN/ Licensed Practical Nurse) said that R6 did not have an active order for oxygen. On 4/22/25 at 12:32 PM, R5 said, I've been using oxygen now for about six months. I don't need it all the time, but I use it sometimes at bedtime because I feel short of breath. At that time, V5 (LPN) said that R5 did not have an active order for oxygen and that the purpose of the oxygen orders are to ensure that everyone (nursing staff) is aware of the need for oxygen. On 4/22/2025 at 12:33 PM, Surveyor and V5 noted an O2 concentrator at R5's bedside and oxygen tubing lying on her bed. R5 stated that the oxygen tubing on her bed and the oxygen concentrator at the side of her bed was hers. On 4/23/2025 at 1:10 PM, V2 (DON/ Director of Nursing) said that an oxygen order from a physician is needed to administer oxygen to a resident in the facility. Surveyor asked if R5 and R6 had been receiving O2. V2 said that she was unsure how long R5 and R6 had been receiving oxygen in the Page 1 of 2 145764 145764 04/23/2025 Morgan Park Healthcare 10935 South Halsted Street Chicago, IL 60628

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility. Surveyor asked if obesity, COPD or malignant neoplasm possibly warrant the need for supplementary oxygen. On 4/23/2025 at 1:10 PM, V2 said, Yes, if a person had COPD with another diagnosis such as obesity or malignant neoplasm of the lung, he/ she could become short of breath and require oxygen at times. A resident could go into respiratory distress if the correct O2 order is not obtained or followed. Facility Oxygen report dated 4/22/2025 includes R5 and R6 as residents receiving supplementary oxygen in the facility. R5's Order Summary Report dated 4/22/2025 excludes any order for oxygen; R5's admission record documents an admission date of 11/08/2016. R6's Order Summary Report dated 4/22/2025 excludes any order for oxygen; R6's admission record documents and admission date of 3/15/2025. Facility policy titled Physician orders documents, to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. Facility policy titled admission policy document, prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident. 145764 Page 2 of 2