Health inspection·June 4, 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, interview, and record review the facility failed to maintain resident's continuous positive airway pressure (CPAP) machines or supplies which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for respiratory treatments in a sample of 5. Residents Affected - Some The findings include: On 6/4/25 the facility provided a list of residents using CPAP machines in the facility which included R1-R5. 1. R1's Facesheet printed on 6/4/25 showed R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure and obstructive sleep apnea. On 6/4/25 at 9:30 AM, R1 was in his room watching television. R1's CPAP machine was sitting on the nightstand next to the bed. R1 stated he has used the same mask, water tank, and tubing (heated coil tubing) for the machine for over a year. R1 stated prior to coming here he would get supplies delivered every 3-6 months depending on what the item was. R1 stated he had lung issues and did not want to get sick. R1 stated he used a pillow pad mask when using the CPAP machine. R2 stated this was the only mask which had worked for him. The facility has brought other masks, but they are the ones that sit over your nose. R1 stated he had attempted to us that kind of mask before, but they do not seal well on R1's face. R1 stated he cannot sleep if he does not use the CPAP at night. R1 stated he has been washing the same tubing and mask using the sinks tap water which is probably not good for the plastic. R1's machine usage log showed R1 has used the machine consistently for the last 30 days. R1's current careplan printed on 6/4/25 showed R1's CPAP careplan was initiated on 3/9/23. There is no reference to CPAP supplies time frames in the careplan. R1's Physician Order Summary printed on 6/4/25 showed no orders for new CPAP supplies. This Summary showed a start date order for R1 to use a CPAP device on 5/31/23. 2. R2's Facesheet printed on 6/4/25 showed R2 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea. R2's Facility assessment dated [DATE] showed R2 to be cognitively intact. On 6/4/25 at 8:35 AM, R2 was in their room eating breakfast. R2's CPAP machine was sitting on the nightstand next to the bed with the tubing and mask laying across R2's pillow. The tubing for R2's machine had a brownish discoloration about halfway along the tubing. R2 stated the tubing or mask has Page 1 of 3 145818 145818 06/04/2025 Rock River Health Care 707 West Riverside Boulevard Rockford, IL 61103

F 0695 Level of Harm - Minimal harm or potential for actual harm not been changed since she got to the facility. R2 stated she brought the machine with her from home. R2's machine had droplet marks of an unknown liquid on it. R2's machine's usage log showed R2 had used the machine consistently for the last 30 days. R2's order summary showed no orders for a CPAP device or reordering for CPAP supplies. Residents Affected - Some R2's current careplan printed on 6/4/25 showed no care areas related to R2 using a CPAP device. 3. R3's Facesheet printed on 6/4/25 showed R3 was admitted to the facility on [DATE] with diagnoses which included sleep apnea. On 6/4/25 at 10:30 AM, R3 was in their room. R3's CPAP machine was on the bedside table with new tubing in its bag. R3 stated they had just brought in the tubing. R3 stated he had not used the CPAP in a while. R3 stated he needed a new mask, and the masks the facility provided were not sealing appropriately so he stopped using the machine. R3's machine usage log had no entries for the last 30 days. R3's Physician Orders printed on 6/4/25 showed R1 had an order for using an AutoPAP (self adjusting air pressure) with a start date of 6/20/24. These orders showed no order to replace AutoPAP supplies. R3's Careplan printed on 6/4/25 showed no focus for sleep apnea or utilization of the AutoPAP device. 4. On 6/4/25 at 8:45 AM R4 and R5's CPAP devices were on their nightstands. R4 and R5's CPAP machines were covered in a dust film. R4's tubing was hanging down the front of the nightstand with the mask resting on the floor. R5s machine water tank was sitting on top of the machine with a white crusted substance inside the tank. R5's tubing was wrapped up on the nightstand. R4 and R5's devices usage logs showed no machine usage for the last 30 days. On 6/4/25 at 8:40 AM, V4 Licensed Practical Nurse stated the CPAP machines are cleaned by the night shift staff. V4 stated they were not sure what cleaning supplies are used to clean the machines. V4 stated the machines need to be cleaned, but did not know when CPAP supplies (masks, tank, tubing) should be exchanged. On 6/4/25 at 10:00 AM, V6 Infection Control Preventionist stated they should be exchange per the manufacturer's guidelines to reduce the infection risk for those residents. V6 stated replacing old or dirty equipment would reduce the resident's risk for respiratory infections. On 6/4/25 at 11:30 AM, V7 Nurse Practitioner stated the facility does have a pulmonology Nurse Practitioner who comes to the facility. V7 said, they had not written any orders for reapplying CPAP supply items. V7 stated over a year is too long to wait to exchange CPAP supplies. CPAP supplies should be exchanged to prevent infections. On 6/4/25 at 12:10 PM, V8 Pulmonary Nurse Practitioner stated they rounded on residents with lung diagnoses. V8 stated he has not written orders for CPAP usage or supplies. CPAP masks and hoses should be changed to reduce the infection risk of the resident. On 6/4/25 at 12:30 PM, V1 Administrator stated they use an online ordering site for CPAP supplies. 145818 Page 2 of 3 145818 06/04/2025 Rock River Health Care 707 West Riverside Boulevard Rockford, IL 61103

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V1 stated they order more when the residents or staff let them know they need something. V1 was not sure how often CPAP supplies should be exchanged. The facility uses a third party company to acquire machines if the residents need a machine. The facility's CPAP Policy dated 11/2022 showed no time frame for exchanging masks, tubing, or water tanks. The 3rd party medical equipment company's CPAP replacement schedule for CPAP equipment showed masks should be replaced every 3-6 months and as needed (PRN), mask cushions 1-2 per month, tubing every 3 months, and water chambers every 6 months. The facility's Infection Control Policy dated 1/2024 showed the policy is to establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases. 145818 Page 3 of 3