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 follow physician orders to ensure resident
received oxygen as prescribed, and failed to properly store oxygen tubing for 1 resident [R9] of 3 [R15,
R272] residents in the sample of 12 residents.
Residents Affected - Few
Findings include,
R9's medical record documents in part: admitted on [DATE], with the medical diagnosis of chronic
obstructive pulmonary disease, hypertensive heart disease syncope and collapse, atrial fibrillation, and
congestive heart failure. Minimum data set brief interview for mental status score = 15 indicates R9 is
cognitively intact. Physician order, dated 2/3/2023, respiratory oxygen per nasal cannula at 1 to 2 liters per
minute continuous titrate to oxygen level is greater than 92% every shift. Care plan, dated 2/3/23,
documents R9 requires oxygen therapy related to chronic obstructive pulmonary disease;
intervention-Administer oxygen per MD orders.
On 02/14/23 at 9:27 AM, R9 stated, I usually have on my oxygen, I don't know how long it has been off, I
would guess it has been over an hour or more, because I'm finished with breakfast. I did not put the oxygen
tubing on the couch. I've been in the bed all morning, and I cannot reach the couch from my bed.
On 2/14/23 at 9:35 AM, surveyor and V4 [Registered Nurse] entered R9's room and observed R9's nasal
cannula tubing lying directly on the seat of the couch. V4 stated, I'm not sure who placed (R9's) nasal
canula on the couch instead of plastic bag. I don't see a plastic bag for (R9's) nasal cannula; I will go get
another nasal canula and plastic bag for storage. The nasal canula lying on the seat of the couch could
cause an infection. (R9) is fine; she does not receive oxygen all the time only as needed.
On 2/14/23 at 1:34 PM, V4 stated, (R9) does have an order for continuous oxygen. I noticed on the shift
report the physician assistant told the nursing staff to start weaning (R9) off oxygen. The nurses are
responsible to remove the oxygen then record the oxygen saturation. I did not remove (R9's) oxygen, and
I'm not sure who did or how long the oxygen was off. I do not see a physician order to wean (R9) off
oxygen; the nurse did not place the order in. Typically, when I get information in report, I follow the plan. I did
not check to see if there was a physician order. I was not the nurse who removed (R9's) oxygen today, and I
am not sure who removed (R9's) oxygen or how long the oxygen was not on (R9).
On 2/16/23 at 11:20 AM, V2 [Director of Nursing] stated, I been working here for 21 years as a floor nurse,
but I been the Director of nursing here for 6 months. I completed one to one in-service
(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:
145869
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
145869
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Estates of Skokie
4626 Old Orchard Road
Skokie, IL 60076
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
with V4 [Registered Nurse] regarding once she receives a verbal order from the physician assistant, to get
the order approved by the primary care physician and enter the order on the resident's electronic
medication administration record. I also in-serviced all other nurses regarding physician orders. If a
resident's oxygen is removed from their airway and not being monitored, the resident could have respiratory
distress or shortness of breath. I also completed one to one in-service with V4 [Registered Nurse] regarding
infection control, that oxygen nasal cannula tubing needs to be stored in a plastic bag when it is not in use
to prevent infection. I also in-serviced all other nursing staff regarding infection control. If the resident
oxygen tubing is not kept in a plastic bag, it could potentially cause an infection.
On 2/16/23 at 1:45 PM, V1[Administrator] stated, The facility does not have a policy on oxygen tubing
storage.
Policy documented in part; Physician's Orders for Medication or Treatments
-Medications will be dispensed and subsequently administered to a resident only upon the clear, complete,
signed order of a lawfully authorized prescriber.
-Verbal orders will be received only by licensed nurses or pharmacists and subsequently confirmed in
writing by the prescribing physician. Each medication order is documented in the resident's medical record
with the date and signature of the person receiving the order
Policy: Documents in part:
-Infection Prevention and Control Program
The primary mission is to establish and maintain an infection prevention and control program designed to
provide a safe, sanitary, and comfortable environment and to help prevent the development and
transmission of communicable diseases and infections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145869
If continuation sheet
Page 2 of 2
