Health inspection·May 12, 2023

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 safely store respiratory care therapy tubing and masks after the therapy. Residents Affected - Some This applies to 5 of 5 residents (R27, R65, R67, R81, and R291) reviewed for respiratory equipment in a sample of 18. Findings include: 1. On 5/10/2023 at 10:01 AM, R81's nebulizer tubing and mouthpiece were observed uncovered and undated. The nebulizer tubing and mouthpiece were hanging from her nightstand and touching the floor. R81's uncovered oxygen tubing was observed on her wheelchair, uncovered and undated. R81's POS (Physician Order Sheet), dated 4/28/2023, showed an order for oxygen at two liters per minute to keep oxygen saturation above 92 percent. On 5/11/2023 at 10:25 AM, V2 (DON-Director of Nursing) stated all oxygen and nebulizer tubing and mouthpieces should be dated to reflect the date the tubings were changed. She said oxygen and nebulizer tubings and mouthpieces should be placed in a plastic bag when not in use for infection control. She said the oxygen and nebulizer tubings and mouthpieces should never be touching the floor. 2. On 5/9/23 at 2:45 PM, R65's oxygen cannula, nebulizer tubing, and mouthpiece were uncovered and undated. R65's face sheet shows a diagnosis of dyspnea, emphysema, obstructive sleep apnea, obstructive sleep apnea, atrial fibrillation, and anxiety. MDS (Minimum Data Set), dated 04/10/2023 shows R65 is cognitively intact. A review of R65's Physician Order Sheet, dated 04/22/2023 and 05/03/2023, showed R65 had orders for oxygen 2 liters per minute per nasal cannula as needed to maintain an oxygen saturation level at 92 percent or above, and an albuterol inhaler three milliliters twice daily and as every four hours as required respectively. Notified V3 (Registered Nurse) walking by in the hallway, and V3 said respiratory tubing and masks need to be stored properly.3. On 5/10/2023 at 9:01 AM, R67's nebulizer tubing and mouthpiece were on top of her nightstand, uncovered, and undated. R67's POS (Physician Order Sheet), dated 4/4/2023, shows an order for Ipratropium-Albuterol inhalation solution 0.5 - 2.5 milligram per 3 milliliters every six hours for shortness of breath. POS, (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 4 Event ID: 146192 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 146192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lisle 2850 Ogden Avenue Lisle, IL 60532 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)