Thrive of Lisle: DNR Wishes Ignored at Death - IL
The resident, identified in inspection records only as R1, was admitted to Thrive of Lisle with moderate dementia. A cognitive assessment placed her score at 11 out of 30, indicating deficits in orientation, attention, recall, executive functioning, and problem solving. She was not someone who could easily advocate for herself in a crisis. She was someone who had already done that work beforehand, at the hospital where she had been treated just before her admission, where she had documented that she wanted a Do Not Attempt Resuscitation order, a DNAR.
That documentation did not follow her in a way that anyone at Thrive of Lisle acted on.
When a social services worker completed an evaluation form after R1's admission, the form asked two questions: Does the resident have an advance directive? The answer recorded was no. Would the resident like assistance with advance directive planning? The answer recorded was also no. The social services designee, identified in the inspection report as V3, confirmed to inspectors that care plan meetings with R1's family had taken place. Code status, she said, was not discussed or followed through for verification. At no point did anyone at the facility contact the family to ask about R1's prior DNAR, despite the fact that R1's daughter was listed as the number one emergency contact in the electronic medical record.
So R1 remained classified as a Full Code.
On the morning of February 22, 2025, R1 was found unresponsive with no vital signs. Staff initiated CPR. They called 911. Paramedics arrived and continued chest compressions as they transported her to the hospital. She arrived at 8:49 a.m. Medical staff continued CPR. At 8:53 a.m., four minutes after she arrived, the code was ended. R1 was pronounced dead. The cause listed on her death certificate was cardiac arrest, driven by heart failure and atrial fibrillation.
Her daughter told inspectors that her mother's wishes had not been honored. R1 had wanted a DNAR. The facility had never verified that. Nobody called. Nobody asked. The family meeting happened, and code status never came up.
What makes this harder to set aside is how straightforward the gap was. This was not a case where a resident's wishes were unknown or ambiguous or locked inside a mind that dementia had already closed off. R1 had expressed her wishes at a hospital before she was admitted to Thrive of Lisle. That record existed. The facility's own policy, reviewed by inspectors, stated that when a resident is admitted, a discussion of advance directives will take place between the resident or family, if the resident is incompetent, and facility staff, so that staff can clearly ascertain how to treat the resident in an emergency.
R1 was moderately cognitively impaired. The policy anticipated exactly this situation. The family was available. The prior hospitalization record existed. The discussion, according to V3, never happened.
Advance directive failures in nursing homes tend to surface in one of two ways. Sometimes a resident who wanted aggressive intervention receives none, because a DNAR order was entered without proper consent or family knowledge. More often, the failure runs the other direction: a resident who wanted to die peacefully, without resuscitation, without chest compressions cracking ribs in the final minutes of life, instead receives the full weight of a code, because the facility never got around to asking.
R1's case is the second kind.
CPR performed on elderly patients with serious cardiac conditions is not a gentle intervention. It is physically violent by design. Survival rates for in-facility cardiac arrest in nursing home populations are low, and the procedure itself can cause rib fractures, internal injuries, and significant distress in the final moments of a person's life. For a patient who had already decided she did not want that, who had made that decision clearly enough to have it documented at a hospital, the failure to verify it is not a paperwork problem. It is a failure to honor a person's stated wishes about her own death.
The inspection was conducted as a complaint investigation. The deficiency was cited under F0578, which covers residents' rights related to self-determination, including the right to formulate advance directives and to have those directives honored. The level of harm was assessed as minimal harm or potential for actual harm, a designation that reflects regulatory classification rather than the experience of R1's daughter, who watched her mother receive a resuscitation her mother had already refused.
V3 did not dispute the facts. She confirmed the family meetings. She confirmed code status was not discussed. The inspection report does not record any explanation for why it was not, or who was responsible for ensuring it was, or whether anyone at the facility had reviewed the prior hospitalization records that contained R1's DNAR documentation before that February morning.
The facility's policy said the conversation would happen. It did not happen. R1 died under a code status she had not chosen.
Her daughter is left with that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thrive of Lisle from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
THRIVE OF LISLE in LISLE, IL was cited for immediate jeopardy violations during a health inspection on November 18, 2025.
The resident, identified in inspection records only as R1, was admitted to Thrive of Lisle with moderate dementia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.