Inspection visit

Health inspectionMarch 27, 2024

THRIVE OF LISLECMS #1461929 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a resident in a dignified manner by not providing personal care assistance for 1 of 16 residents (R177) in the sample of 16 reviewed for dignity. The findings include: R177's admission Record, dated 3/25/24, shows he was admitted to the facility on [DATE], and his diagnoses include, but are not limited to, cerebral infarction (stroke), anarthria (complete loss of speech), major depressive disorder, weakness, and need for assistance with personal care. R177's Care Plan (initiated on 3/18/24) shows R177 has a communication problem and all staff should anticipate and meet his needs. The same care plan also shows R177 is dependent on staff for toileting hygiene and is incontinent and should be checked every two to three hours, and as needed for incontinence. On 3/25/24 at 11:11 AM, R177 was sitting in his wheelchair in his room. R177 appeared to be very thin and was unable to speak, but he typed text messages via his smart phone and communicated with body gestures. When asked how his care was, R177 responded with a so-so hand gesture. R177 said (via typed message) he is wet and has a diaper on, but staff are slow to change him, they don't check on him, and he wants to go back to using a catheter. R177 said he gets very uncomfortable sitting up after 10 minutes because he has no fat and no muscle. R177 hung his head and looked hopeless. R177 triggered his call light at 11:18 AM. By 11:25 AM, no one had responded to his call light, however, multiple staff members were seen walking by his room. There was still no response by 11:34 AM, and finally at 11:39 AM, a CNA (Certified Nursing Assistant), V12, came in and asked R177 what he needed. R177 told her he was wet. V12 said she would be back to put him to bed and change him, then she left and returned at 11:41 AM. On 3/25/24 at 11:41 AM, V12 returned to change R177. V12 said she last changed him at 8:00 AM. V12 said residents are checked and changed every 3 to 4 hours. On 3/25/24 at 1:06 PM, V12 acknowledged R177 had been wet when she responded to his call light at 11:39 AM. On 3/27/24 at 11:44 AM, V1, Administrator, said they strive to answer call lights in less than 10 minutes, and all staff should be responding to call lights. The facility's Resident Rights Policy (revised 5/2023) shows each resident is to be treated with dignity and respect. Staff interactions are supposed to be focused on assisting in maintaining and enhancing self-esteem, self-worth, individualizing goals, preferences and choices. 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 11 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 03/27/2024 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)

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 5. R336's admission Record shows she was admitted to the family on 3/19/24, with diagnoses including diastolic congestive heart failure and pulmonary edema. Residents Affected - Some R336's Order Summary Report, dated 3/27/24, shows an order for daily weights was ordered on 3/19/24 to start on 3/20/24. An order for weekly weights was entered to start 3/23/24. R336's Weight and Vitals Summary shows she was weighed on 3/19/24 and 3/27/24. There were no daily weights noted in R336's weight and vitals summary. R336's Medication Administration Record (MAR) shows that a weight was documented only on 3/20/24. There are blank entries on March 21, 22, and 23, 2024. R336's MAR also shows that she is taking furosemide (diuretic) for edema. On 3/26/24at 2:00 PM, V11, RN (Registered Nurse), said the CNAs (certified nursing assistants) weigh the residents and document it in the computer. V11 said weight gain could signify fluid overload. On 3/27/24at 10:20 AM, V2, DON (Director of Nursing), said standard orders are weigh residents daily for three days and then monthly after that. V2 said daily weights are ordered by the physician when residents have congestive heart failure. Monitoring daily weights helps monitor residents for exacerbation of heart failure. R336's Care Plan initiated 3/19/24, shows obtain and document weights per medical doctor orders and facility protocol. The facility's Weight Policy, revised/reviewed 5/23, shows, All resident will be weighed on admission, readmission, weekly for the first four weeks and then at least monthly. Short term residents with a diagnosis of congestive heart failure will be weighed twice weekly unless otherwise ordered by the physician. Based on interview and record review, the facility failed to do daily weights for residents with congestive heart failure (CHF) and failed to notify the physician of a weight gain for residents with CHF for 5 of 16 residents (R42, R32, R21, R39, and R36) reviewed for quality of care in the sample of 16 . The findings include: 1. On 03/26/24 at 12:30 PM, V18 (Registered Nurse) said residents with CHF are normally weighed daily. V18 added daily weights are done to see if the resident is retaining fluid and if medication/treatment changes are needed. V18 said when a physician is notified of a resident's weight gain, it is documented in the progress notes. R42's Face Sheet showed R42 was diagnosed with CHF. R42's Order Summary Report showed an order for daily weights, and to call the doctor with a weight gain greater then 3 pounds in one day or greater then 5 pounds in one week. R42's Medication Administration Record (MAR) and Weights and Vital Summary report showed missing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 2 of 11 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 03/27/2024 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)

F 0684 weights on 3/14/24 and 3/19/24. Level of Harm - Minimal harm or potential for actual harm R42's MAR showed on 3/15/24 a weight of 200 pounds, and on 3/16/24 a weight of 205.5 pounds (a 5.5 pound gain in one day). R42's MAR showed on 3/21/24 a weight of 205 pounds, and on 3/22/24 a weight of 211.6 pounds (a 6.6 pound gain in one day). Residents Affected - Some R42's Progress Notes for 3/16/24 and 3/22/24 did not indicate R42's doctor was notified of the weight gain. 2. R32's Face Sheet showed R32 was diagnosed with CHF R32's Order Summary Report showed an order for daily weights, and to call the doctor with a weight gain grater then 3 pounds in one day or grater then 5 pounds in seven days. R32's MAR and Weight and Vital Summary report showed missing weights on 3/9/24, 3/10/24, 3/11/24, 3/19/24, 3/23/24, 3/24/24, and 3/25/24. R32's MAR showed on 3/15/24 a weight of 248.3 pounds and on 3/16/24 a weight of 259.4 pounds (a 11.1 pound gain in one day). R32's Progress Notes for 3/16/24 did not indicate R32's doctor was notified of the weight gain. 3. R21's Face Sheet showed R21 was diagnosed with CHF. R21's Order Summary Report showed an order for daily weights and to call cardiology with a 2-3 pound weight gain overnight or 3-5 pound gain in one week. R21's MAR and Vital Summary report showed missing weights on 3/9/24, 3/10/24, 3/11/24, 3/23/24, 3/24/24, and 3/25/24. 4. R39's Face Sheet showed R39 was diagnosed with CHF. R39's Order Summary Report showed and order for daily weights. R39's MAR and Vital Summary report showed missing weights on 3/8/24, 3/9/24, 3/10/24, and 3/24/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 3 of 11 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 03/27/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for a pressure injury dressing and failed to have pressure relieving devices in place for 2 of 4 residents (R328, R227) reviewed for pressure injuries in the sample of 16. Residents Affected - Few The findings include: 1. R328's admission Record shows she was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, weakness, dementia, and malnutrition. R328's Pressure Injury Risk, dated 3/24/24, shows she is at risk for developing pressure injuries. R328's Wound Assessment and Details Report shows she has an unstageable pressure injury to her sacrum. R328's Care Plan, initiated 3/18/24, shows evaluate and treat per physicians orders. R328's Treatment Administration Record (TAR), dated 3/1/24 to 3/31/24, shows and order for, Coccyx wound-cleansed with normal saline, pat dry, apply medihoney to wound bed and calcium alginate. Cover with foam dressing three times a week and as needed if missing/soiled, monitor for signs and symptoms of infection every day shift every Tuesday, Thursday, and Saturday. R328's TAR shows that R238's dressing was not changed on 3/23/24 as ordered. On 3/25/24 at 2:22 PM, R328 had a foam dressing intact to her coccyx. The dressing was dated 3/21/24. There was tan drainage visible through the foam dressing. On 3/26/24 at 9:45 AM, there was no dressing noted to R328's coccyx. V6, Wound Care Registered Nurse, said she did not know where R328's dressing was. V6 said the dressing could have possibly came off during incontinence care. V5, Wound Care Nurse Practitioner, said R328's coccyx wound has a lot of dead tissue present. V5 said the floor nurses can also change residents' pressure injury dressings. V5 said that medihoney is used to deride the wound and acts as an antibiotic. V5 said calcium alginate is an absorbent material and the foam dressing is for extra protection. On 3/26/24 at 10:00 AM, V7, LPN (Licensed Practical Nurse), said she was R328's nurse for the day. V7 said she did not know V7's coccyx dressing was not on. At 10:10 AM, V8, Certified Nursing Assistant/CNA, said she got R328 up in her wheel chair at about 8:45 AM. V8 said R328 did not have a dressing in place to her coccyx at that time. At 2:00 PM, V11, RN (Registered Nurse), said if a residents' dressing comes off, then the cna needs to let the nurse know right away. The purpose of the dressing is to help prevent infection and to stop the wound from getting worse. 2. R227's Wound Assessment Report, dated 3/20/24, showed R227 was at high risk for skin breakdown and had a pressure injury on her right heel. R227's orders show an order to off load heels. R227's Skin Impairment care plan listed under interventions to, Ensure that heels are elevated while resident is lying in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 4 of 11 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 03/27/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/25/24 at 09:55 AM, R227 was in bed. R227's feet were not covered up. R227's heels were resting directly on the mattress. There were green heel protector boots sitting in the chair next to R227's bed. R227 said staff sometimes put the heel protector boots on. On 03/25/24 at 11:42 AM and 03/26/24 at 08:40 AM, R227 was in bed with her heels resting directly on the mattress. On 3/26/24 at 9:26 AM, V4 (Wound Care Nurse) said R227 had a pressure injury on her right heel. V4 said R227's heel protector boots are a pressure injury prevention and R227 should have the heel protector boots on while in bed. On 3/26/24 at 12:30 PM, V19 (Certified Nursing Assistant) said she was familiar with R227 and R227 did not refuse care. The facility's Wound Policy and Procedure policy, revised on 5/23, shows, Any resident with a wound receives treatment and services consistent with the resident's goal of treatment. Typically the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condtiions necessitate palliative care as the primary focus. Resident risk factors and interventions are documented including: impaired mobility, need for pressure relief such as support surfaces, repositioning, pressure relieving devices, and general treatment regimen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 5 of 11 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 03/27/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor for 1 of 4 residents (R179) reviewed for catheters in the sample of 16. The findings include: R179's admission Record, dated 3/25/24, shows R179 was admitted to the facility on [DATE], hospitalized from [DATE] to 3/21/24, and readmitted to the facility on 3/2124. R179's diagnoses include, but are not limited to, congestive heart failure, chronic kidney disease, and atherosclerotic heart disease. R179's Care Plan, initiated on 3/21/24, shows he has a urinary catheter. On 3/25/24 at 10:16 AM, R179's urinary catheter bag was resting directly on the floor on the right side of his bed. On 03/26/24 at 12:10 PM, V14, Certified Nursing Assistant, said a urinary catheter bag needs to be in a privacy bag to protect the resident's privacy and it should not be on the floor to prevent contamination The facility's Catheterization of Urinary Bladder Policy (revised 4/2023) shows the urinary collection bag should be kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 6 of 11 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 03/27/2024 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff supplied a resident with his tube feeding for 1 of 3 residents (R177) reviewed for tube feeding in the sample of 16. The findings include: R177's admission Record, dated 3/25/24, shows he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, severe protein calorie malnutrition, dysphagia (difficulty swallowing foods or liquids), cerebral infarction (stroke), anarthria (complete loss of speech), gastrostomy status, major depressive disorder, weakness, and need for assistance with personal care. R177's current Care Plan provided by the facility (undated) shows R177 requires tube feedings due to inadequate oral intake, dysphagia, abnormal weight loss, and severe malnutrition. R177's Order Summary Report dated 3/25/24 shows R177 is to receive tube feedings continuously for 22 hours a day at a rate of 55 milliliters (ml) per hour; the tube feeding can be off for two hours a day for therapy and activities of daily living. The order was written and started on 3/19/24. R177's Dietary note of 3/25/24 at 1:25 PM shows his continuous tube feedings are to continue infusing until 11:00 PM on 3/25/24. On 3/25/24 at 10:16 AM, there was a pole with a tube feeding pump on it in R177's room. R177 was not in his room, and there was a board in his room indicating he had therapy at 10:00 AM. On 3/25/24 at 11:11 AM, R177 was sitting in his wheelchair in his room. There was a tube feeding pump on a pole in his room, but it was not in use; no tube feeding liquid or tubing was hanging, nothing was connected to R177's gastrostomy tube, and nothing was infusing. Staff arrived to change him at 11:41 AM, and no tube feeding was initiated. R177 was seen at 1:06 PM and again at 1:34 PM, without his tube feeding infusing. On 3/25/24 at 1:39 PM, R177's Registered Nurse (RN), V13, said he doesn't know when R177's tube feeding is supposed to be infusing, but he would look up his orders. V13 said he has not hooked R177 to his tube feeding yet today. On 3/26/24 at 12:40 PM, V15, Registered Dietician, said R177 was on continuous tube feedings for 22 out of 24 hours per day through 3/25/24. V15 said R177 is underweight and the tube feedings are calculated to meet 100 % of his nutritional needs. V15 said R177 should have been on continuous tube feedings up until 11:00 PM on 3/25/24. The facility's Tube Feeding Policy (revised 5/2023) shows continuous tube feedings are based on individual resident need per Registered Dietician assessment and delivered over a 24 hour period. An order by the physician/nurse practitioner contains the type of formula and rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 7 of 11 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 03/27/2024 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)

F 0694 Provide for the safe, appropriate administration of IV fluids 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 measure a PICC (peripherally inserted central catheter) tubing and failed to measure a midline intravenous catheter tubing for 2 of 4 residents (R42 and R6) reviewed for intravenous access in the sample of 16. Residents Affected - Few The findings include: 1. On 3/26/24 at 12:50 PM, R42 had an midline intravenous access to his upper arm. R42's Order Summary Report showed orders to measure the external midline intravenous catheter every seven days and to measure the upper arm circumference every seven days. R42's Medication Administration Record (MAR) showed the external catheter and arm circumference were to be measured on 3/14/24 and 3/21/24. There were no recorded value for the measurements on 3/14/24 and 3/21/24. 2. On 3/26/24 at 12:29 PM, R6 had a PICC in her upper arm. R6's Order Summary Report showed and order to measure the external catheter length of the PICC every seven days. R6's MAR showed the external catheter of the PICC was measured on 3/17/24 and the next measurement was to be done on 3/24/24. There was no recorded value for the PICC measurement on 3/24/24. On 03/26/24 at 01:02 PM, V18 (Registered Nurse) said PICC and midlines are measured to ensure the catheters have not been pulled out and remain in the correct location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 8 of 11 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 03/27/2024 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to serve residents the required 8 ounce (oz) portion of chicken pot pie for lunch. This applies to 4 of 16 (R32, R39, R54, R31) residents reviewed for portion sizes in the sample of 16. The findings include: On 3/25/24 at 12:33 PM, V22 (Cook) began plating the noon meal. The noon meal consisted of chicken pot pie, green beans, a dinner roll, and pumpkin mousse. Facility Diet Spreadsheet shows the portion size for chicken pot pie is 8 oz. V22 was using a #8 scoop for service, which provides 4 oz. V22 was serving each plate with two scoops of chicken pot pie. On 3/25/24 at 12:42 PM, the food service pan holding the chicken pot pie looked like it was getting low and might run out before service was ending. V22 began plating the food for the residents on the 3000 hall. V22 was serving a single #8 scoop, which provides 4 oz of volume, to each plate on the 3000 hall. On 3/25/24 at 12:53 PM, V23 (Food Service Director) said there was extra chicken pot pie in the oven available if needed. At 12:56 PM, V21 (Cook) brought more chicken pot pie filling in a food service pan with cooked portions of puff pastry to be used to complete service. On 3/25/24 at 1:02 PM, V22 finished serving lunch. Residents on the 3000 hall were not provided an additional half portion of chicken pot pie or a substitute during lunch service. R32's lunch meal ticket for 3/26/24 shows R32 was to receive chicken pot pie. R39's lunch meal ticket for 3/26/24 shows R39 was to receive chicken pot pie. R54's lunch meal ticket for 3/26/24 shows R54 was to receive chicken pot pie. R31's lunch meal ticket for 3/26/24 shows R31 was to receive chicken pot pie. On 3/26/24 at 11:07 AM, V23 said V22 could have told V23 or V21 that the chicken pot pie was running low, and V22 required more to continue service in order to provide those residents with the full serving. V23 said if residents do not receive the appropriate portion sizes, they can be at risk for weight loss by not receiving their their daily required nutrition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 9 of 11 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 03/27/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to fully submerge a plate and tray in the three-compartment sink for at least 30 seconds. This failure has the potential to effect all residents residing in the facility. The findings include: The Centers for Medicare and Medicaid form 671, dated 3/25/24, shows there are 65 residents residing in the facility. On 3/25/24 at 10:54 AM, V20 (Dietary Aide) washed her hands and went to the clean and sanitized outfeed side of the dish machine. While removing plates from the dish racks, V20 took one of the plates to the three-compartment sink next to the dish machine area, washed it in the first sink, rinsed it in the second sink, and proceeded to dip the plate into the third sink filled with pre-diluted sanitizing solution and immediately removed it. V20 then placed the plate back onto the dish rack to air dry. On 3/25/24 at 11:06 AM, V20 grabbed a tray from one of the dish racks and again proceeded to wash it in the first sink, rinse it in the second sink, and dipped it a total of three times in the third sink filled with pre-diluted sanitizing solution. V20 removed the tray immediately after each time it was dipped. V20 then placed the tray back onto the dish rack to air dry. On 3/26/24 at 1:29 PM, V23 (Food Service Director) said all dishes should be fully submerged for at least 30 seconds before being removed from the three-compartment sink. If dishes are removed before 30 seconds, any potential bacteria on the dishes would not be fully killed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 10 of 11 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 03/27/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff changed their gloves and performed hand hygiene after providing peri care to 1 of 16 residents (R12) reviewed for infection control in the sample of 16. Residents Affected - Few The findings include: R12's admission Record, dated 3/26/24, shows her diagnoses include, but are not limited to, need for assistance with personal care. On 3/25/24 at 10:25 AM, V12, Certified Nursing Assistant (CNA), used gloved hands to wipe R12's bottom after she had a BM. V12 did not remove/change the gloves or perform hand hygiene and proceeded to pull up R12's brief, adjust her gown, and use a gait belt to transfer R12 back into her wheelchair. On 3/26/24 at 12:10 PM, V14, CNA, said gloves should be changed after wiping a resident to prevent contamination because the gloves are soiled. The facility's Hand Hygiene Policy (revised April 2023) shows gloves should be removed promptly after use, before touching non-contaminated items and environmental surfaces, and to decontaminate hands after removing gloves by appropriate hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 11 of 11

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Citations

9 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

FAQ · About this visit

Common questions about this visit

What happened during the March 27, 2024 survey of THRIVE OF LISLE?

This was a inspection survey of THRIVE OF LISLE on March 27, 2024. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THRIVE OF LISLE on March 27, 2024?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·March 27, 2024