Inspection·July 26, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to place the nebulizer mask in a plastic bag after use for 2 of 8 (R24, R39) residents in a sample of 24. Residents Affected - Few Findings include: On 7/23/24 at 11:10 AM, R24's nebulizer mask was observed on top of the bedside counter without any covering. On 07/23/24 at 11:20 AM, observed R39's nebulizer mask inside the drawer without a covering. On 07/25/24 at 11:41 AM, observed R39's nebulizer mask inside the drawer without a covering. On 7/23/24 at 11:24 AM, V15 (Licensed Practical Nurse) opened the drawer and said R39's nebulizer mask should be covered and not just placed inside the drawer. On 7/23/24 at 11:26 AM, V15 (Licensed Practical Nurse) said R24's nebulizer mask should be covered in a bag when not in use. On 07/25/24 at 11:43 AM, V2 (Director of Nursing) opened R39's drawer and the nebulizer mask was without a covering. V2 said the nebulizer mask should be covered when not in use. Facility's policy on Nebulizer Therapy- Revised 5/2023. Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: Care of the Equipment 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 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: 146187 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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)