Inspection·June 25, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify a change in condition in a timely manner. This applies to 1 of 16 residents (R23) reviewed for quality of care in the sample of 16. Residents Affected - Few The findings include: R23's face sheet shows she is a [AGE] year old female admitted on [DATE]. Her face sheet lists her diagnoses to include: peripheral vascular disease, chronic heart failure, non-ST elevation (NSTEMI) myocardial infarction (heart attack), atrial fibrillation, chronic kidney disease stage 3, hypertension, and muscle weakness. R23's progress notes dated 6/21/25 at 2:58 PM shows, pt (patient) c/o (complained of) not feeling well, refused breakfast, and lunch. Drank 240cc (cubic centimeter) of fluids at lunch, nothing for breakfast. T99.3 (temperature) Tylenol given at 1230 (12:30 PM) c/o shortness of breath, sats (oxygen saturation) 89% on ra (room air), applied oxygen at 2 liters per n/c (nasal cannula). 1430 (2:30 PM (2 hours later)) reassessed by 2 nurses, abdominal breathing noted and heart rate is irregular. Called V14 Nurse Practitioner (NP), sending to local ER (emergency room) for evaluation . R23's progress notes dated 6/21/25 at 8:04 PM shows, pt admitted to local hospital for non-stemi (heart attack) diagnosis. On 6/24/25 at 11:06 AM, V11 Registered Nurse (RN) stated she was the nurse that sent R23 out on 6/21/25. That morning she was sitting in her room not eating or drinking. R23 was saying she was short of breath and it was hard to breathe. V11 said R23's oxygen saturation was 89% in the morning. She said she notified V14 NP who told her to put oxygen on R23 and keep an eye on her. (There is no documentation in R23's medical record of that conversation/order). She also stated, R23 doesn't normally wear oxygen. When another nurse came in for PM shift, they assessed her together and that is when they decided to send her out. She stated the only documentation was the progress note at 2:58 PM. I should have documented more. The local hospital initial admission note dated 6/21/25 shows, History of Present Illness: Patient reports that she has been short of breath going on for the last few days, denies having any cough. Patient also with increased lower extremity swelling The facility's change of condition process policy dated 2/4/25 shows, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Procedure: The facility must inform the resident, consult with the resident's (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 7 Event ID: 146071 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 146071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Place of Belvidere 1701 5th Avenue Belvidere, IL 61008 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)