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 one resident (R3) had the proper
equipment for a daily CPAP (Continuous Positive Airway Pressure) machine as ordered by a Medical
Doctor. This failure has affected one of four residents reviewed for improper nursing care.
Residents Affected - Few
Findings include:
R3 is [AGE] year old with diagnoses including but not limited to: obstructive sleep apnea, chronic systolic
heart failure, history of sudden cardiac arrest, presence of automatic cardiac defibrillator and essential
hypertension.
On 06/24/2024 during investigation R3 was observed lying in bed.
On 06/24/2024 at 12:15 PM R3 stated, I am ok. I get help when I need it. No one here mistreats me. I just
need help with my CPAP. I haven't had my CPAP for two nights and it is hard to breath at night. I really need
my CPAP. They say that a piece is missing from my CPAP. Can you help me?
Surveyor observed R3's CPAP machine sitting on her night stand. The CPAP was without a face mask.
On 06/24/2024 at 12:17 PM, V16 (RN/Registered Nurse) stated, I worked days on Saturday and was told
that R3's mask was missing from her CPAP machine. The person that orders supplies has been off and I'm
not sure who orders supplies in her absence.
On 06/25/2024 at 12:02 PM, V10 (Respiratory Therapist) stated, I am a contractor here. I don't order
respiratory supplies, the facility does. I believe the nursing department or central supplies orders all of the
respiratory equipment and supplies such as CPAP machines, masks, tubing, etc. I follow residents who
have unstable respiratory conditions and prevent them from being hospitalized . I am familiar with R3. I was
off on Monday, but I was going to go and visit her because I was told that she was missing a mask for her
CPAP machine.
Surveyor inquired about the purpose of a CPAP machine.
On 06/25/2024 at 12:02 PM, V10 stated, The CPAP machine is used to help residents breathe easier
during sleep. This is usually prescribed for residents with sleep apnea. Without the CPAP machine, the
resident's CO2 may increase, O2 saturation may decrease and heart rate increases. Overtime, increased
CO2 in the blood and altered mental status can occur.
Surveyor inquired about V2's knowledge of R3's missing CPAP mask.
(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:
145510
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
145510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara Lincoln Park
1366 West Fullerton Avenue
Chicago, IL 60614
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
On 06/26/2024 at 1:40 PM, V2 (DON/ Director of Nursing) stated, I was made aware of R3's missing mask
on Monday. I asked V3 (Assistant Administrator) to order the mask because the person that does central
supplies was off.
Surveyor inquired about the importance of a resident using the CPAP at night time as ordered?
Residents Affected - Few
On 06/26/2024 at 1:40 PM, V2 (DON) stated, The CPAP machine is prescribed for a reason. We must
follow that order so that the resident is safe while sleeping.
R3's Order Summary Report documents, CPAP at 5 bedtime.
R3's Care Plan documents, R3 is at risk for altered respiratory status/ difficulty breathing related to sleep
apnea. Interventions: CPAP settings are titrated pressure, 5 cmH20 via full face mask at bedtime.
R3's Medication Administration note dated 6/23/2024 documents, mask missing.
R3's Medication Administration note dated 6/22/2024 documents, mask not available.
Facility policy titled CPAP/BiPAP support documents, Purpose: to improve arterial oxygenation in residents
with respiratory insufficiency, obstructive insufficiency, obstructive sleep apnea or restrictive/ obstructive
lung disease; to promote resident comfort and safety.
Facility policy titled Respiratory Therapy Equipment Use documents, It is the facility policy to ensure that
oxygen and nebulizer equipment use is compliant with the acceptable standards of practice.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145510
If continuation sheet
Page 2 of 2
