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
interview and record review, the facility failed to provide oxygen therapy according to professional standards
for a resident (R1) experiencing low oxygen levels. This applies to 1 of 3 residents reviewed for oxygen
therapy in the sample of 4.
Residents Affected - Few
The findings include:
R1's electronic face sheet printed on 1/10/24 showed R1 has diagnoses including but not limited to surgical
amputation, chronic respiratory failure with hypoxia, generalized anxiety disorder, peripheral vascular
disease, congestive heart failure, and ischemic cardiomyopathy.
R1's facility assessment dated [DATE] showed R1 had mild cognitive impairment, respiratory failure, and
heart failure.
R1's care plan dated 1/2/24 showed, (R1) has an altered respiratory status/difficulty breathing related to
chronic respiratory failure .give oxygen as ordered by the physician, elevate head of bed,
monitor/document/report abnormal breathing patterns to physician .
R1's nursing progress notes dated 1/5/24 showed, This writer was attending to resident's roommate and
heard the resident breathing loudly with shallow breaths. Upon investigation, the resident's face was pale
and displayed signs of shortness of breath with labored breathing patterns vitals were immediately taken
and oxygen saturations fluctuating between 80-82%.
R1's local emergency medical services (EMS) run report dated 1/5/24 showed, Upon arrival patient was
found lying in bed .in respiratory distress on a non-rebreather at 4LPM (liters per minute) with pulse
oximetry reading of 54% .crew increased patient's oxygen to 15LPM .with the increase in oxygen patient's
status did improve, patient was more alert and responding to questions .
On 1/10/24 at 10:49AM, V7 (Licensed Practical Nurse-LPN) stated, If a resident is found with difficulty
breathing, I would immediately check their oxygen levels. If their oxygen levels are dropping, I would place
them on a non-rebreather mask at 15LPM. It would not be effective at 4LPM because you're not providing
enough oxygen to them. I was the one who placed the mask on (R1) and I'm sure I would have put it on at
15LPM, but I don't see it documented anywhere . (R1's medical record showed no documentation that V7
placed her on 15LPM of oxygen while utilizing the non-rebreather mask)
On 1/10/24 at 1:16PM, V11 (Nurse Practitioner) stated, I don't know what the exact number is for a
non-rebreather mask, but I know it has to be at least 12LPM to achieve proper oxygenation. The resident
should have been placed on the mask, oxygen increased to at least 12LPM and then (V7) should
(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:
145868
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
145868
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara Long Grove
1666 Checker Road
Long Grove, IL 60047
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
have continuously monitored her oxygen levels until EMS arrived to ensure she was getting enough oxygen
and keeping her oxygen saturation levels up. She was at a critical level when they arrived and seemed to
improve for a while with the increased oxygen level .
On 1/10/24 at 10:34AM, V5 (LPN) stated, If a resident's oxygen levels begin to drop, I would increase their
oxygen and then recheck their oxygen saturations. If the levels continue to drop, I would place them on a
non-rebreather mask at 12LPM and then recheck the levels again to ensure they are improving. If you put a
non-rebreather mask on at 4LPM that's not effective because they aren't going to get the full amount of
high flow oxygen that they need to increase their oxygenation.
The facility's policy titled, Oxygen Therapy and Administration dated 7/28/23 showed, Oxygen therapy shall
be administered to patients as indicated and upon a physician's order .Purpose: To assure adequate
oxygenation to all spontaneously breathing and ventilator dependent patient .Non-Rebreather flow rates:
8-12LPM.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145868
If continuation sheet
Page 2 of 2
