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 (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 3 Event ID: 145818 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 145818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rock River Health Care 707 West Riverside Boulevard Rockford, IL 61103 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)