GROVE OF FOX VALLEY,THE
For profit - Individual
158 Beds
LEGACY HEALTHCARE
Data: November 2025
Trust Grade
68/100
#149 of 665 in IL
Photo by The Grove of Fox Valley
Photo by The Grove of Fox Valley
Photo by The Grove of Fox Valley
1 / 6 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Grove of Fox Valley in Aurora, Illinois has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #149 out of 665 facilities in Illinois, placing it in the top half, and #10 out of 25 in Kane County, meaning there are only nine local options that are better. The facility is improving, having reduced its issues from 10 in 2024 to 7 in 2025. Staffing is considered a strength with a 3/5 rating and a low turnover of 29%, much better than the state average of 46%, which means staff members tend to stay longer and are familiar with the residents. There have been no fines reported, which is a positive sign, and the facility has better RN coverage than 80% of Illinois facilities, ensuring that registered nurses can address issues that may be overlooked by other staff. However, there are some weaknesses to consider. A serious incident occurred where a resident was transferred improperly, resulting in a foot fracture, highlighting potential concerns about adherence to care plans. Additionally, there were findings related to the improper handling of controlled medications and the failure to assess residents for self-administration of medications, which could pose risks to safety. Overall, while there are strengths in staffing and RN coverage, families should remain aware of these specific incidents and the need for ongoing improvements.
- Trust Score
- C+
- In Illinois
- #149/665
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 29% annual turnover. Excellent stability, 19 points below Illinois's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ✓ Good
- Each resident gets 54 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
68/100
Top 22%
Needs review
10 → 7 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 7 issues
The Good
-
Low Staff Turnover (29%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (29%)
19 points below Illinois average of 48%
Facility shows strength in staff retention, fire safety.
The Bad
Chain: LEGACY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 25 deficiencies on record
1 actual harm
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents that a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents that are dependent on staff assistance with activities of daily living (ADLs). This applies to three of seven residents (R1, R2, and R3) reviewed for incontinence care.
The finding includes:
R1, a [AGE] year-old, admitted on [DATE]. R1's diagnoses included diabetes mellitus, other disease of anus/rectum, ulcerative colitis, major depression, neuropathy, and fractures of the 4th and 5th thoracic vertebrae. The MDS (Minimum Data Set) dated March 16, 2025, indicates R1 is cognitively intact (BIMS (Brief Interview Mental Status) score of 15/15) and requires staff assistance with ADLs, including incontinence care. The care plan dated March 24, 2025, directs staff to provide incontinence care every two hours and as needed.
R2, a [AGE] year-old, admitted on [DATE]. R2's diagnoses included right below-knee amputation, diabetes mellitus, peripheral vascular disease, gastroenteropathy. The MDS dated [DATE], shows R2 is cognitively intact (BIMS score 15/15) and dependent on staff for hygiene and incontinence care. The care plan dated April 25, 2025, directs incontinence care every two hours and as needed.
R3, a [AGE] year-old admitted on [DATE]. R3's diagnoses included diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and diarrhea. The MDS dated [DATE], documents R3 as severely cognitively impaired and requiring extensive staff assistance for ADLs, including incontinence care. The care plan dated April 4, 2025, instructs provision of incontinence care every two hours and as needed.
On April 25, 2025, at 11:00 A.M., R1 was observed with a saturated incontinence brief. V8 (CNA), at this time provided incontinence care to R1. V8 stated that incontinence care for R1, R2, and R3 (roommates) was delayed due to V7 (Certified Nursing Assistant /CNA) leaving the facility for personal reasons. V8 reported that incontinence care was subsequently provided to R2 at 10:30 A.M. and to R3 at 10:45 A.M. Both R2 and R3 were also found to have soaked incontinence briefs. During this time of observation, R1 stated that the last incontinence care and brief change were provided by V9 (CNA) during the night shift around 5:00 A.M. R2 and R3 similarly reported that their last incontinence care was also performed by V9 at approximately 5:00 A.M.
On April 25, 2025, at 5:45 P.M., V9 validated that she had provided incontinence care for R1, R2, and R3 between 5:00 A.M. and 5:30 A.M. that morning.
At 5:10 P.M. on the same day, V7 (CNA) stated that she was assigned to R1, R2, and R3 for the day shift starting at 6:00 A.M. on April 25,2025. V7 reported that although she began providing care to other residents, she did not provide incontinence care or brief changes to R1, R2, and R3 before leaving the facility at 9:30 A.M.
At 11:30 A.M., (same day), V17 (R1's Power of Attorney) expressed concern, stating that it remains a concern that (R1) was not provided incontinence care and that his brief was not changed until 11:00 A.M., which happens almost daily.
At 2:10 P.M., (same day) V18 (R3's Power of Attorney) stated that during her daily visits, R3 was often found soaked with urine and that staff would blame different shifts for the delay in care.
The EMR (Electronic Medical Record) showed the following:
-R1, a [AGE] year-old, admitted on [DATE]. R1's diagnoses included diabetes mellitus, other disease of anus/rectum, ulcerative colitis, major depression, neuropathy, and fractures of the 4th and 5th thoracic vertebrae. The MDS (Minimum Data Set) dated March 16, 2025, indicates R1 is cognitively intact (BIMS (Brief Interview Mental Status) score of 15/15) and requires staff assistance with ADLs, including incontinence care. The care plan dated March 24, 2025, directs staff to provide incontinence care every two hours and as needed.
-R2, a [AGE] year-old, admitted on [DATE]. R2's diagnoses included right below-knee amputation, diabetes mellitus, peripheral vascular disease, gastroenteropathy. The MDS dated [DATE], shows R2 is cognitively intact (BIMS score 15/15) and dependent on staff for hygiene and incontinence care. The care plan dated April 25, 2025, directs incontinence care every two hours and as needed.
-R3, a [AGE] year-old admitted on [DATE]. R3's diagnoses included diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and diarrhea. The MDS dated [DATE], documents R3 as severely cognitively impaired and requiring extensive staff assistance for ADLs, including incontinence care. The care plan dated April 4, 2025, instructs provision of incontinence care every two hours and as needed.
Jan 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow a physician's order to obtain a referral for a Corneal Speci...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow a physician's order to obtain a referral for a Corneal Specialist. This applies to 1 of 1 resident (R77) reviewed for vision services in the sample of 27.
The findings include:
The EMR (Electronic Medical Record) showed R77 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, chronic kidney disease, and type 2 diabetes.
On January 6, 2025, at 10:20 AM, R77 said he has a hard time seeing and had a referral from the eye doctor but has not had an appointment made for him yet.
On January 7, 2025, at 12:04 PM, V16 (Social Services) said she received an email from R77's POA (Power of Attorney) on December 19, 2024, requesting R77 have an appointment at a local eye clinic. V16 said she was out of the office until December 27, 2024, and on December 27, 2024, V16 notified V17 (R77's Nurse) to start the process to schedule the appointment for R77. V16 said she followed up with V17 today, and V17 had not started the process to schedule R77's appointment.
An Eye Doctor note dated November 27, 2024, by V22 (Eye Doctor) showed Assessment and Plan, Diagnoses: Central corneal opacity, right eye. Care Plan: Consult with Corneal Specialist.
R77's Order Summary Report dated January 7, 2025, showed an order dated November 27, 2024, for Refer to Cornea Specialist for scars on the right cornea by [V22].
As of January 7, 2025, at 12:00 PM, the facility did not have documentation to show R77 had an appointment scheduled for a corneal specialist.
On January 8, 2025, at 2:32 PM, V2 (DON/Director of Nursing) said there should not have been a delay in R77 receiving a corneal specialist appointment. V2 continued to say R77's appointment should have been scheduled when the order was received in November.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide specialized mattress for a resident with wors...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide specialized mattress for a resident with worsening acquired pressure injury wound in accordance with wound care practitioner recommendation and their policy.
This applies to 1 of 4 residents (R54) reviewed for pressure injury wounds in the sample of 27.
The findings include:
R54's medical record showed R54 admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, presence of malignant neoplasm of the breast, presence of cardiac pacemaker, osteoarthritis of the hip, and bilateral nuclear cataract and open angle glaucoma.
R54's MDS (Minimum Date Set) dated October 10, 2024, showed R54 was moderately cognitively impaired, and required assistance with ADL (activities of daily living) care including set up assistance with eating and oral hygiene, partial assistance with upper body dressing, personal hygiene and rolling right and left in bed, and substantial assistance with bed mobility, transfer, lower body dressing, toileting and bathing.
R54's Braden risk assessment dated [DATE], showed R54 was at high risk for developing a pressure injury wound.
R54's wound care progress note dated November 19, 2024, showed R54 had developed a pressure injury to the bilateral glute (upper buttock), assessed to be a stage 2 and measured 1.5 cm (centimeter) X 1.1 cm X 1 cm, with a surface area of 1.65 square cm. The wound base contained 10% epithelial tissue, and 90% granulation tissue.
On January 8, 2025, at 10:03 AM, wound dressing change was observed on R54. V20 LPN (Licensed Practical Nurse/ wound care nurse) and V21 CNA (Certified Nursing Assistant) repositioned R54 to her left side on the bed and V20 changed the dressing to the bilateral glute. V20 described the mattress in use for R54 as a two-tone pressure redistribution mattress. V20 stated R54 needs more help repositioning now because she is weaker and could use a low air loss mattress. R54's wound bed contained slough and V20 validated the wound had progressed to a stage 3.
R54's most recent wound care progress note dated January 2, 2025, showed R54's bilateral glute wound measured 1.3 cm X 1.1 cm X 0.01 cm with calculated surface area of 1.43 cm and was assessed to be a stage 3 pressure injury wound. The wound care progress note of January 2, 2024, also showed R54 would benefit from an alternating air/low air loss mattress for pressure redistribution.
The facility's policy titled Skin Regimen and Treatment Formulary dated January 24, 2024, showed .Procedures .9. Residents with Stage III and/or IV pressure injuries will be placed in specialized air mattresses like Low Air Loss mattress with an incontinence brief only .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that interventions were applied to provide com...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that interventions were applied to provide comfort and prevent further worsening of resident's contracted hands.
This applies to 2 of 3 residents (R17 and R41) reviewed for range of motion in the sample of 27.
The findings include:
1). R17's face sheet showed her to be a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Congestive Heart Failure, Lack of coordination, Shortness of Breath, Chronic Kidney Disease, Major Depressive Disorder and Dementia. R17's Minimum Data Set (MDS) dated [DATE] showed R17 to be cognitively intact and that R17 required partial/moderate assistance for upper body dressing.
R17's physician order dated September 26, 2024 showed the following: Apply rolled gauze to left hand contracture.
On January 6, 2025 at 10:19 AM, R17 left hand was tightly closed and appeared contracted. R17 was not holding anything in her hand.
On January 6, 2025 at 12:10 PM, R17 is lying in bed, her left hand was again observed tightly closed and appeared contracted and R17 was not holding anything in her hand.
On January 7, 2025 at 10:10 AM, R17 stated she has received a bath already. R17's left hand was again observed tightly closed and appeared contracted and R17 was not holding anything in her hand.
On January 7, 2025 at 2:46 PM, R17 left hand appeared contracted and she was not holding anything in her hand. R17 stated that no one has put anything in her left hand for a least week. R17 stated when carrot is used it does do some good. R17 stated she tried to put the carrot in her left hand but she couldn't.
On January 7, 2025 at 3:29 PM, V18 (Restorative/RN) stated the R17 is being seen by restorative. V18 stated that R17 should have a role gauze in her left hand for treatment of the left hand contracture at all times except during ADL (Activities of Daily Living) care. V18 stated that the CNA's (Certified Nursing Assistants) should be applying the gauze. In R17's room, V18 uncovered R17 left hand and R17 did not have anything in her left hand. V18 tried to open R17 fingers on her left hand, and R17 screamed in pain. V18 stated that rolled gauze should be in R17 left hand.
R17's left impaired mobility care plan as of January 7, 2025 at 3:20 PM showed the following: Pat dry and apply Roll wash cloth to bilateral hands. Then was changed the same day to the following: Apply Rolled Gauze/Kerlix to left hand, after AM ADL care, check skin, wash hand with warm water, Pat dry and apply roll gauze to bilateral hand. Apply all time. Change every morning.
2. R41's face sheet showed her to be a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Chronic Systolic Heart Failure, Weakness, Anemia in Chronic Kidney Disease, Hypertensive Heart and Chronic Kidney Disease, Quadriplegia, Major Depressive Disorder, Type 2 Diabetes, Dementia, and Personal History of Transient Ischemic Attack. R41's MDS dated [DATE] showed R41 to be cognitively impaired and that R41 required substantial/maximal assistance for upper body dressing.
R41's physician order summary dated September 26, 2024 showed the following: Apply rolled gauze to right hand contracture. There was no mention of the left hand contracture.
On January 6, 2025 at 10:17 AM, R41's left hand appeared contracted and closed. R41 was not holding anything in her left hand.
On January 6, 2025 at 12:26 PM, R41 was not holding anything in her right or left hands. R41's left hand appeared contracted and closed. V19 (Licensed Practical Nurse) stated R41 needs a towel in her left hand.
On January 7, 2025 at 2:35 AM, R41 was not holding anything in her left hand.
On January 7, 2025 at 3:39 PM, R41 did not have anything in her left hand that appeared contracted. When surveyor asked R41 if anyone put a towel or anything in her left hand in the last couple days, R41 shook her head left to right, no. When R41 was asked how long has it been since she had placed anything in her left hand, R41 shrugged her shoulders. When asked has it been a while since she has had anything in her hand, R41 shook her head up and down, yes. V18 stated that R41 should have rolled gauze in her left hand. V18 tried to open R41's left contracted hand and R41 screamed in pain.
R41's left impaired mobility care plan as of January 7, 2025 at 3:20 PM showed the following: Pat dry and apply Roll wash cloth to bilateral hand. Then was changed and read: Nursing Restorative Program as indicated, Apply Rolled gauze to left hand after AM ADL care and remove during meal and bedtime.
On January 9, 2025 at 9:15 AM, V18 stated that R17 and R41's orders for rolled gauze to be placed in their contracted hands is a treatment to soften or loosen the contractures. V18 stated that having the gauze in the hand is also a more comfortable position for the resident's hands, and it helps to prevent worsening of the contractures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide a diet that includes the resident's diet preference.
This applies to 1 of 1 resident (R137) reviewed for dining in th...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to provide a diet that includes the resident's diet preference.
This applies to 1 of 1 resident (R137) reviewed for dining in the sample of 27.
The findings include:
R137's diagnoses on face sheet celiac disease, other seizures, difficulty in walking, not elsewhere classified, unspecified lack of coordination, acute respiratory failure, unspecified whether with hypoxia or hypercapnia.
R137's admission MDS (minimum data set) dated December 12, 2024 included that R137 was cognitively intact.
R137's diet order on Physician Order Summary included NAS (No Added Salt) diet, Regular texture, Thin liquids consistency, Gluten Free.
R137's care plan revised on December 13, 2024 showed that R137 is at risk for alteration in nutritional status related to R137 is on a therapeutic diet. Interventions included to provide diet and supplements as ordered.
On January 6, 2025, at 11:59 AM, R137 received room tray with chicken breast with no gravy, cooked carrots, a carton of 2% milk, 4 oz/ounce container of yogurt and a slice of white bread placed in a disposable sandwich bag. R137 stated They gave me a slice of white bread even though I am gluten free. I got celiac disease. R137 also added that it is not the first time he received regular bread. R137's diet card showed gluten free: no wheat, breads, etc. V9 (Guest Services) who was in the hallway was notified about resident concerns and she stated that she would in turn notify the dietary department of the same.
On January 7, 2025 at 11:47 AM, R137 received a room tray served by V9. The tray included a meal of beef tips with no gravy, baked potato and Italian blend vegetables, 4 oz container of yogurt, and a dinner roll in a disposable sandwich bag. R137's diet card showed gluten free: no wheat, breads, etc. When asked if the roll was gluten free, V9 stated that she would have to have to ask the dietary department.
On January 7, 2025 at 11:49 AM, V7 (Dietary Manager) stated that the dinner roll is not gluten free and that R137 should not have received it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy for antibiotic stewardship to ensure residents r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy for antibiotic stewardship to ensure residents received the appropriate antibiotic for an infection.
This applies to 2 of 2 residents (R15 and R32) reviewed for antibiotic use in the sample of 27.
The findings include:
1. The EMR showed R15 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart and chronic kidney disease with heart failure, neuromuscular dysfunction of the bladder, and stage four pressure ulcer of the sacrum.
On January 8, 2025, at 11:34 AM, V4 (Infection Preventionist Nurse) said R15 was started on ciprofloxacin (antibiotic) on October 23, 2024, for a urinary tract infection. V4 said R15's antibiotic timeout was completed on October 26, 2024. V4 continued to say when she completes the antibiotic timeout, V4 is checking to make sure a provider has seen the resident since the antibiotic was started and writes a progress note about the antibiotic. V4 said she does not review the urine culture results as part of the timeout. V4 said R15's urine culture was resulted on October 26, 2024, and showed R15's urinary tract infection was resistant to ciprofloxacin. V4 continued to say R15's new antibiotic was not started until October 28, 2024.
R15's Laboratory Results showed R15's urine culture results were reported to the facility on October 26, 2024, at 9:47 AM. The results showed R15's urinary tract infection was resistant to ciprofloxacin.
R15's Order Listing Report dated January 8, 2025, showed an order dated October 23, 2024, for ciprofloxacin 250 mg (milligrams), give one tablet by mouth every 12 hours for urinary tract infection for seven days. The report continued to show the ciprofloxacin was discontinued on October 27, 2024. The report showed an order dated October 27, 2024, for Fosfomycin oral pack 3 grams, give one packet by mouth one time a day every three days for urinary tract infection.
R15's October 2024 MAR (Medication Administration Record) showed R15 received the first dose of Fosfomycin on October 28, 2024.
The facility's October 2024's Infection List showed R15's infection occurred on October 23, 2024, and ciprofloxacin was started on October 23, 2024. The documentation continued to show a timeout was performed on October 26, 2024, but R32's antibiotic was not changed until October 28, 2024.
The facility does not have documentation to show an antibiotic timeout was completed three days after the initial dose of antibiotic to ensure R15 was on the appropriate documentation.
The facility does not have documentation to show a provider was notified of R15's urine culture results on October 26, 2024.
On January 8, 2025, at 11:59 AM, V2 (DON/Director of Nursing) said when V4 conducts the antibiotic timeout, V4 should be reviewing the urine culture to ensure the resident is on the appropriate antibiotic. V2 said the antibiotic timeout should include V4 checking with the nurse practitioner that a resident is on the correct antibiotic for the infection. V2 continued to say the resident's nurse could also notify the nurse practitioner when laboratory results are received. V2 said a facility staff member should be notifying the nurse practitioner when laboratory results are received to ensure the correct antibiotic is being given to the resident.
2. R32's EMR showed R32 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, chronic kidney disease, and acute respiratory failure.
On January 8, 2025, at 11:34 AM, V4 said R32 was started on ciprofloxacin for a urinary tract infection on November 7, 2024. V4 said R32's urine culture results came back on November 10, 2024, but R32's antibiotics were not changed until November 11, 2024. V4 continued to say V4 completed R32's antibiotic timeout on November 10, 2024, and V4 did not look at the urine culture results.
R32's Laboratory Results Report showed R32's urine culture results were reported on November 10, 2024, at 11:42 AM. The results showed R32's urinary tract infection was resistant to ciprofloxacin.
R32's November 2024 MAR showed R32 started receiving ciprofloxacin on November 7, 2024. The MAR continued to show R32's antibiotic was changed on November 12, 2024.
The facility's November 2024's Infection List showed R32's infection occurred on November 7, 2024, and ciprofloxacin was started on November 7, 2024. The documentation continued to show a timeout was performed on November 10, 2024, but R32's antibiotic was not changed until November 12, 2024.
The facility does not have documentation to show an antibiotic timeout was completed three days after R32's ciprofloxacin was started to ensure R32 was on the appropriate antibiotic.
The facility does not have documentation to show a provider was notified of R32's urine culture results on November 10, 2024.
The facility's policy titled Antibiotic Stewardship Program Policy dated July 12, 2024, showed Policy Statement: The facility will comply with federal regulations in establishing an antibiotic stewardship program. Procedures . 6) Perform Antibiotic Timeout: Three days after the initial dose of antibiotic was started, a formal process of reassessment of the ongoing need for and choice of antibiotic is required to be performed by the clinical team an during this period, culture results is in already, and date such as resident's clinical response to antibiotic or alternative explanation for resident's status change is now available. Questions included in this process include: Does the resident have a bacterial infection that will respond to antibiotics? If so, is the resident on the most appropriate antibiotic, dose, and route of administration? .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that blister packs containing controlled ...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that blister packs containing controlled medications are maintained intact to ensure safe and effective use of the medications.
This applies to 5 of 5 residents (R23, R49, R52, R81 and R103) reviewed for controlled medications in the sample of 27.
The findings include:
1. On January 7, 2025 at 10:44 AM with V13 (Assistant Director of Nursing), the Restorative Hall medication cart shift change accountability record for controlled substances showed that the first shift on and off nurses' initials for January 7, 2025 were not documented by both the in-coming and out-going shift nurses to ensure that all controlled medications were accounted at the start of the shift. Inside the controlled medication compartment, multiple controlled medications were observed including:
- R49's blister pack of Pregabalin 25 mg (milligram), dispensed by the pharmacy on January 2, 2025 originally containing 30 tablets. The said blister pack of Pregabalin 25 mg had 28 tablets remaining that were intact and sealed (from #1 through #28). Review of R49's controlled drug administration record form for the Pregabalin 25 mg showed that there should be 29 tablets remaining in the blister pack. V14 (Registered Nurse) stated that she (in-coming nurse) and the evening out-going nurse completed the shift-to-shift narcotics/controlled substance count that morning and acknowledged that they did not sign the shift change accountability record for controlled substances for January 7, 2025. V14 stated that there was one missing Pregabalin tablet because she did not sign out on R49's controlled drug administration record form when she gave the resident's medication that morning during the medication pass.
- R49's blister pack of Hydrocodone-APAP (Acetaminophen) 5-325 mg, dispensed by the pharmacy on June 4, 2024 originally containing 30 tablets. The said blister pack of Hydrocodone-APAP 5-325 mg had 30 tablets remaining that were intact and sealed (from #1 through #7, from #9 through #15, from #17 through #22 and from #24 through #30), while there were 3 additional tablets with broken seal at the back (#8, #16 and #23). V13 stated that the blister pack seal of any controlled medication should be kept intact to ensure its integrity and if the seal is broken the controlled medication should be wasted and witnessed by another nurse.
2. On January 7, 2025 at 11:10 AM with V13 the 500 Hall medication cart was observed with multiple controlled medications including:
- R52's blister pack of Tramadol 50 mg, dispensed by the pharmacy on December 19, 2024 originally containing 30 tablets. The said blister pack of Tramadol 50 mg had 27 tablets remaining that were intact and sealed (from #1 through #27). Review of R52's controlled drug administration record form for the Tramadol 50 mg showed that there should be 28 tablets remaining in the blister pack. V15 (Registered Nurse) stated that there was one missing Tramadol tablet because she did not sign out on R52's controlled drug administration record form when she gave the resident's medication that morning at around 9:00 AM. Review of R52's medication administration audit report showed that the resident received Tramadol 50 mg on January 7, 2025 at 9:00 AM, administered by V15.
- R103's blister pack of Alprazolam 0.25 mg, dispensed by the pharmacy on December 11, 2024 originally containing 30 tablets. The said blister pack of Alprazolam 0.25 mg had 25 tablets remaining that were intact and sealed (from #1 through #6 and from #8 through #26), while there was one (1) additional tablet with broken seal at the back (#7).
- R23's blister pack of Oxycodone IR (Immediate Release) 5 mg, dispensed by the pharmacy on December 30, 2024 originally containing 30 tablets. The said blister pack of Oxycodone IR 5 mg had 29 tablets remaining that were intact and sealed (from #1 through #29). Review of R23's controlled drug administration record form for the Oxycodone IR 5 mg showed that there should be 30 tablets remaining in the blister pack. V15 who was the nurse on duty cannot explain why there was one (1) tablet of Oxycodone IR missing from the blister pack. Review R23's medication administration audit report showed that the resident received Oxycodone IR 5 mg on January 7, 2025 at 9:02 AM, administered by V15.
- R23's blister pack of Lorazepam 0.5 mg, dispensed by the pharmacy on January 5, 2025, originally containing 30 tablets. The said blister pack of Lorazepam 0.5 mg had 30 tablets remaining that were intact and sealed (from #1 through #30). Review of R23's controlled drug administration record form for the Lorazepam 0.5 mg showed that there should be 29 tablets remaining in the blister pack. V15 stated that she gave one (1) tablet of Lorazepam 0.5 mg to R23 at around 9:20 AM that morning during the medication pass but cannot explain why there were still 30 tablets remaining in the blister pack. Review R23's medication administration audit report showed that the resident did not receive her Lorazepam 0.5 mg on January 7, 2025 during V15's shift.
3. On January 7, 2025 at 11:40 AM with V13, the 300 Hall medication cart was observed with multiple controlled medications, including R81's blister pack of Alprazolam 0.5 mg, dispensed by the pharmacy on December 12, 2024 originally containing 30 tablets. The said blister pack of Alprazolam 0.5 mg had eight (8) tablets remaining that were intact and sealed (from #1 through #5, #7 and from #9 through #10), while there were two (2) additional tablets with broken seal at the back (#6 and #8).
On January 7, 2025 at 5:06 PM, V2 (Director of Nursing) stated that the nurse should immediately sign the controlled drug administration record form after the controlled medication was taken out of the blister pack or container to properly account the medication and to prevent discrepancies. V2 stated that the seal of the controlled medication blister packs should not be broken to ensure medication integrity. According to V2, if the controlled medication's seal has been broken it should be discarded/wasted and signed out by 2 nurses to prevent potential diversion of medication. During the same interview V2 stated that the incoming and the outgoing nurses should sign or initial the shift change accountability record for controlled substances to ensure that the narcotics/controlled substances are all accounted and documented.
The facility's policy regarding Controlled Medications Count last reviewed and revised by the facility on July 26, 2024 showed, It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. The same policy under procedure showed in-part, 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR (electronic Medication Administration Record). 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication.
The facility's policy regarding Medication Labels last revised on November 19, 2018 showed in-part under procedure, 7. Medication containers having soiled, damaged, incomplete, illegible, confusing, or makeshift labels are destroyed in accordance with the medication destruction policy.
Mar 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its advance directives policy. This applies to 2 of 10 (R40 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its advance directives policy. This applies to 2 of 10 (R40 & R14) reviewed for advance directives in a sample of 31.
Findings include:
1. On 3/12/2024 at 2:56 PM, R40's EMR (Electronic Medical Record) review was completed and did not show an order indicating his advance directives.
R40's EMR showed he was admitted to the facility on [DATE] and was receiving hospice services. R40 had an advance directive form dated 1/27/2021 indicating he was a DNR (Do Not Resuscitate) with selective medical treatment interventions. R40's Order Summary Report dated 3/14/2024 showed a physician order indicating DNR code status was entered on 3/12/2024 (during the survey).
2. On 3/12/2024 at 1:53 PM, R14's EMR review was completed and did not show an order indicating his advanced directives.
R14's EMR showed he was admitted to the facility on [DATE]. R14's EMR did not show an advance directive form. R14's Order Summary Report dated 3/13/2024 showed a physician order indicating full code status was entered on 3/12/2024 (during the survey).
On 3/13/2024 at 2:20 PM, V12 (Licensed Practical Nurse/LPN) said they enter a physician order in the residents' EMRs to indicate if they are full code or DNR to make staff aware of the residents' advance directives.
On 3/13/2024 at 2:36 PM, V2 (Director of Nursing/DON) said a code status order is entered in the residents' EMRs and if needed the staff looks at the POLST forms to confirm advance directives.
The facility's policy, titled Advance Directives with a revised date of 2/19/2024, showed Upon admission: .2. Staff will provide the resident and/or representative with information regarding advance care planning which will address types of Advance Directives, treatment options and refusal of treatment. 3. Information will be reviewed and the resident and/or representative will be asked to sign and acknowledge that they have received the information on Advance Care Planning. 4. An Advance Directive form (as provided by the healthcare facility) shall be completed with resident and/or legal representative to verify treatment options as well as code status. 5. Appropriate information will be added to Physician Order Sheet (POS). 6. The resident's Advanced Directive choices/options shall be reviewed during the re-assessment and quarterly care planning process. 7. Discussion of Advance Directives and treatment options/refusals will be addressed in appropriate chart documentation as well as a care planned during the admission process, as indicated. 8. Staff will initiate choice discussion concerning the DNR option or Full Code .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure R24 was free from physical restraint. This app...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure R24 was free from physical restraint. This applies to 1 of 1 resident (R24) reviewed for physical restraints in a sample of 31.
Findings include:
The EMR (Electronic Medical Record) showed R24 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, paraplegia, and functional quadriplegia. R24's MDS (Minimum Data Set) dated 1/01/2024 showed R24 required substantial to maximal assistance from staff for upper body dressing.
On 3/12/2024 at 12:29 PM, R24 was sitting in her high-back wheelchair in the dining room with a seatbelt around her waist.
On 3/14/2024 at 11:11 AM, V7 (Certified Nurse Assistant/CNA) and V8 (CNA) assisted R24 into her high-back wheelchair. V8 applied a push-button seatbelt around R24's waist area. R24 tried several times to release the seatbelt but was not able to, R24 said she could not do it because it was too hard. V8 said R24 sometimes could not release her seatbelt.
On 3/14/2024 at 11:35 AM, V6 (Restorative Nurse) said there were no residents in the facility with the use of restraints. V6 said a restraint was any device that could restrict a resident, including a seatbelt if a resident could not physically release it. V6 said the use of restraints requires an assessment, consent, physician order, and care plan to monitor the resident. V6 said she was not aware of R24 using a seatbelt when up in her wheelchair.
On 3/14/2024 at 11:59 AM, a review of R24's Active Order Summary Report did not show any order for a self-releasing seatbelt.
R24's Restorative assessment form dated 1/02/2024 showed R24 had a limited range of motion to her bilateral wrists and hands and no evaluation for the use of a seatbelt device when up in wheelchair.
The facility's policy, titled Restraints with a revised date of 7/28/2023, showed Policy Statement It is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience .Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets ALL the following criteria: A) attached or adjacent to the resident's body B) that the individual cannot intentionally remove easily, and C) restricts freedom of movement or normal access to one's body.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist with discharge planning. This applies to 2 of 3 residents (R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist with discharge planning. This applies to 2 of 3 residents (R106 and R14) reviewed for discharges in a sample of 31.
Findings include:
1. The EMR (Electronic Medical Record) showed R106 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, alcohol abuse, and carotid artery stenosis. R106's MDS (Minimum Data Set) dated 12/07/2023 showed R106 was cognitively intact. The MDS continued to show R106 did not require the use of a mobility device and required setup or clean-up assistance with his personal hygiene care.
On 3/12/2024 at 10:50 AM, R106 said he liked the facility, but he wanted to be discharged back to the community. R106 said he was independent with his care. R106 said he could not recall if facility staff had spoken to him about his discharge goals.
2. The EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including cellulitis to lower limbs and difficulty walking. R14's MDS (Minimum Data Set) dated 2/23/2024 showed R14 was cognitively intact. The MDS continued to show R14 transfer assessment was not completed.
On 3/13/2024 at 9:20 AM, R14 said he had recently been admitted to the facility and felt ready to be discharged back to his assistive living facility. R14 said he was now able to transfer in and out of his wheelchair which was his goal to be able to transfer into his motorized wheelchair. R14 said he did not have a care plan meeting with any facility staff to discuss his discharge goals.
R14's Physical Therapy Treatment Encounter Note dated 3/13/2024 showed R14 was able to perform stand-pivot transfer into his wheelchair with therapy instructions.
On 3/13/2024 at 3:14 PM, V2 (Director of Nursing/DON) said R106 had expressed wanting to be discharged to another facility a while back. V2 said social services sent a referral to another facility but R106 was not accepted and was now a long-term resident at the facility. V2 said social services assist with the discharge planning process. V2 said she reviewed R106 and R14's EMRs and could not find documentation of R106's discharge planning or R14's care plan meeting for discharge planning.
On 3/13/2024 at 3:37 PM, V3 (Social Service Director) said she was not too familiar with R106 and R14. V3 reviewed their EMRs and was unable to find discharge planning documentation. V3 said R106 did not qualify for an assisted living facility because he was too young, and she would talk to him to identify proper placement. V3 said the facility should be assisting residents with the desire to be discharged . V3 said during care plan meetings they discuss discharge planning with the residents or their responsible parties and identify discharge needs.
On 3/14/2023 at 9:14 AM, V3 said she met with R14 on 3/13/2024 to discuss discharge planning and his therapy goals to be discharged safely back to his assisted living facility. V3 said she was planning to document his care plan meeting later today. V3 said the facility did not have a care plan meeting policy but they follow the residents' MDS schedule for meetings. V3 continued to say they meet with long-term residents quarterly and discuss discharge goals and confirm if they are still long-term care residents, and for short-term residents they try to meet with them within 48-72 hours after admission to discuss discharge goals.
The facility's policy, titled Discharge Planning and Instructions with a revised date of 7/26/2023, showed Procedure 1. Discharge planning shall be initiated by the facility on resident admission and re-evaluated quarterly .3. Social services shall evaluate each resident's discharge planning potential in collaboration with the facility's interdisciplinary team e.g. nursing, therapy, dietary and attending physician. 4. Social services shall help coordinate resident discharge potential and appropriateness .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 3/12/2024 at 10:24 AM, R104 was in bed praying. R104 was unable to communicate because she was non-English speaking and ha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 3/12/2024 at 10:24 AM, R104 was in bed praying. R104 was unable to communicate because she was non-English speaking and had no communication device available.
On 3/13/2024 at 2:24 PM, V11 (Certified Nurse Assistant/CNA) and V10 (Licensed Practical Nurse/LPN) said they take care of R104, and she was non-English speaking, and did not know her language. They said they use hand gestures to communicate with her when providing care. They said R104 never had a communication binder or board.
R104's EMR (Electronic Medical Record) showed an admission date of 5/17/2023 for long-term care services. R104's care plan reviewed on 3/13/2024 showed a focus problem for communication language: [R104] has potential for some difficulty in expressing self and understanding others. My primary language is Mosalese a dialect from an area in [NAME]. R104's care plan showed an intervention for the use of a communication board to be able to express her needs to staff.
The facility's policy, titled Communication Board with a revised date of 7/27/2023, showed Policy Statement: It is the policy of this facility to utilize a communication board/device to help augment method and strategy for communication between the facility personnel and resident either due to language barrier and/or communication impairments e.g. aphasia. Procedure: 1. The communication board/device shall be provided to the resident presenting language barrier and/or impairments in communication by activity/social service department on date of admission .3. The indications for the use communication board must be relayed to the resident's direct care providers and appropriate disciplines by the facility .5. The communication board must be readily accessible to the resident at all times .
Based on observation interview and record review the facility failed to utilize communication tools for the use of residents and staff. The facility failed to provide written information in the residents preferred language.
This applies to 3 of 3 residents (R21, R104 and R114) reviewed for communication in a sample size of 31.
Findings include:
1. R114 was admitted to the facility on [DATE]. R114's MDS (Minimum Data Set) dated 1/27/24 shows she is cognitively intact with BIMS (Brief interview for Mental Status) score of 13.
On 3/12/24 at 1:15 PM, V19 and V20 Family Members were visiting R114 in her room. V20 had to assist V19 in spelling her name for the surveyor. V20 stated R114 speaks and reads in Spanish only. V20 stated he and V19 speak some English but V19 reads only Spanish. V20 stated he does not read well in English. Both V19 and V20 stated they preferred to receive written information in Spanish. V20 stated R114 would be discharged home with V19 her primary family caregiver.
On 3/14/24 at 8:49 AM, V4 RN (Registered Nurse) stated R114 is provided education verbally and written forms. V4 stated written materials that are provided to R114 have been in English.
On 3/14/24 at 10:11 AM, V3 Social Services Director stated some teaching materials are provided in English and are verbally translated by staff or R114's family. V3 stated when R114 is discharged home her discharge instructions will be in English. V3 stated it is more beneficial for written information provided in a manner that R114's primary care giver can understand. If the resident and her family are not proficient in English written information will not be beneficial to them.
Review of R114's admission contract provided to and signed by R114 was in English.
R114's Care plan dated 2/6/24 identifies a communication foreign language barrier with a primary language is Spanish. The set goal is for R114 to learn to express basic wants and needs in English or via communication aid. Intervention in place for R114's health literacy includes use of materials to support understanding / comprehension, such as using large print and using the preferred language verbally and in print having the advocate / representative present to help explain the material using reasonable repetition.
2. R21 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) shows R21 is cognitively impaired with a BIMS (Brief Interview for Mental Status) Score of 3.
On 3/14/24 at 8:40 AM, Surveyor obtained V5 C.N.A. (Certified Nursing Assistant) to assist with communication with R21 who was speaking fervently at surveyor. V5 stated she did not know what language R21 spoke. V5 stated she communicates with R21 using hand gestures. V5 stated she speaks Spanish and some of R21's words sound similar. V5 stated there was no communication board or language line aids available.
On 3/14/24 at 8:49 AM, V4 RN (Registered Nurse) stated she did not understand R21 when she is talking. V4 stated she thought R21 spoke Indian or Endu but was not sure. V4 stated there was a language line but she did not know how to access it. V4 stated she uses hand gestures to communicate with R21.
On 3/14/24 at 10:11 AM, V3 Social Services Director stated R21 speaks Hindi and a mixture of [NAME]. V3 stated R21 should have a translation (Communication) board in her room for staff to reference.
On 3/14/24 at 10:20 AM, V3 Social Services Director went to R21's room with surveyor, no communication board was available. R21 began to fervently speak and pointing. V3 stated R21 wanted to go to bed. V3 stated she did not speak R21's language. V3 stated she knew what R21 wanted by her gestures and her usual routine.
R21's care plan dated 2/28/24 identifies a communication foreign language focus. R21's primary language is Hindi. The intervention for R21 is to utilize an augmentative communication device (communication board).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor lab value medications for cardiac/anti-rhythmic (high risk)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor lab value medications for cardiac/anti-rhythmic (high risk) medications. This applies to 1 of 1 resident (R43) reviewed for high risk medications in a sample of 31.
The findings include:
R43 was admitted to the facility on [DATE]. R43's EMR (Electronic Medical Record) shows the following diagnoses of hypertensive heart and chronic kidney disease with heart failure and stage 1 though stage 4 chronic kidney disease or unspecified chronic kidney disease, chronic combined systolic (congestive) and diastolic (congestive) heart failure, heart failure, heart disease and atherosclerotic heart disease heart disease of native coronary artery without angina pectoris.
R43's Physician Order Sheet (POS) shows the order for Digox Oral Tablet 125mcg (Digoxin) give 1 tab by mouth every 72 hours for CAD (coronary artery disease). R43's care plan (initiated 5/31/18) shows that R43 is using digoxin related to Congestive Heart Failure (CHF)/atrial flutter with interventions to monitor serum digoxin levels every 6 months.
On 3/14/24 at 8:15 AM, V2 (DON/Director of Nursing) said that R43 is on digoxin. V2 said the initial order date for digoxin was 5/30/18, and R43 was placed on digoxin for CAD and heart failure. V2 said that R43 initial documented lab work for digoxin levels was on 8/20/18 and the last documented digoxin lab levels was done on 3/22/22; the digoxin levels were less than 0.19ng/ml (reference range is 0.80-2.0ng/ml-nanogram per millimeter). V2 said digoxin levels are checked to monitor for toxicity. V2 said the facility does not have a policy that addresses monitoring of digoxin levels.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to change a loose and soiled midline dressing. This appli...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to change a loose and soiled midline dressing. This applies to 1 out of 2 residents (R17) reviewed for peripheral lines in a sample of 31.
Findings include:
R17's admission Records documents he was initially admitted on [DATE]. R17 was re-admitted to facility on 2/6/2024. R17's EMR (Electronic Medical Record) documents diagnosis of osteomyelitis of vertebra, sacral and sacrococcygeal region. R17's March 2024 POS (Physician Order Sheet) documents an order for Ceftriaxone 2 grams every 24 hours via midline for nine days. R17's Progress Notes on 3/7/2024 documents a midline catheter was inserted on his right upper arm for antibiotic infusion.
Separate observations on 3/12/2024 at 11:02 AM, 3/13/2024 at 9:45 AM and 3/13/2024 at 10:30 AM showed R17 had a transparent dressing dated 3/7/2024. Both right and left side of the dressing was loose and not adhering to R17's skin. Blood was noted on the gauze under the clear dressing.
On 3/13/2024 at 9:45 AM, R17 said that his midline was inserted on 3/7/2024. He said the gauze and the clear dressing has not been changed since then.
On 3/13/2024 at 10:30 AM, V13 (RN-Registered Nurse) said the dressing change is due on 3/14/2024.
On 3/14/2024 at 10:15 AM, V2 (DON-Director of Nursing) said midline dressing should be changed weekly and as needed. She said if dressing is bloody and coming off, she expects the nurses to change the dressing to make sure the dressing is intact and clean to prevent increased risk of infection on site.
Facility's Policy on Intravenous Therapy dated 7/30/2014 and revised on 8/7/2023 documents the following: .Procedures .2.b. All midline catheter dressing are to be done every 7 days while following the procedure for dressing change of central lines. The extremity circumference will be measured weekly to monitor for edema.c. All central line dressing (PICC) (peripherally inserted central catheter) lines, single and multi-lumen central catheters inserted in subclavian, jugular, or inguinal area) will be changed every 7 days and PRN (as needed).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
3) On 3/12/24 at 11:25 AM, R37's mask used for nebulizer treatment is left on the nightstand undated and uncovered. The cup to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
3) On 3/12/24 at 11:25 AM, R37's mask used for nebulizer treatment is left on the nightstand undated and uncovered. The cup to pour the nebulization solution is wet and attached to the mask.
On 3/13/24 at 9:31 AM, R37's mask used for nebulizer treatment is left on the nightstand undated and uncovered. The cup to pour the nebulization solution is wet and attached to the mask.
On 3/14/23 at 9:30 AM, V12 (LPN - Licensed Practical Nurse) stated, after nebulization treatment, the mask and the medicine container must be washed, dried and stored in a plastic bag, to prevent contamination thereby preventing potential problem of respiratory infection to the resident.
On 3/14/24 at 10:40 AM, V2 (DON-Director of Nursing) stated, after nebulization treatment is over, the medicine cup should be rinsed with water, dried and stored in plastic bag to avoid collecting dust and thereby preventing potential problem of respiratory infection.
On 3/13/24 03:35 PM R37's facesheet showed, R37 is admitted on [DATE] with diagnoses to include Right Hemiplegia, Delusional disorder, Metabolic encephalopathy and Chronic Kidney Disease. R37's MDS (Minimum Data Set) showed severe cognitive impairment. His medications included Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML (milligrams/milliliter) (Ipratropium-Albuterol) 1 application inhale orally every 12 hours related to Chronic Obstructive Pulmonary Disease.
Based on observation, interview, and record review, the facility failed to appropriately contain respiratory equipment. This applies to 3 of 3 residents (R20, R37, R85) reviewed for oxygen in a sample of 31.
The findings include:
1. On 3/12/24 at 11:32 AM, R20 was lying in bed. Behind her was an end table with her CPAP (Continuous Positive Airway Pressure) machine, tubing and face mask. The tubing and face mask were not in a bag. R20 stated she was not sure if her tubing was ever changed.
R20's face sheet shows diagnoses that include chronic respiratory failure with hypoxia and obstructive sleep apnea.
R20's POS (Physician Order Sheet) shows an order of CPAP 5-20 CM (Centimeters) water with heated humidity with full face mask, on at night and off in AM.
2. On 3/12/24 at 11:50 AM, surveyor went to R85's room. She was not present. R85's BPAP (Bilevel Positive Airway Pressure) machine was on an end table next to her bed. The tubing and face mask were not in a bag. R85's nasal cannula and tubing that was under her pillow was not stored in a bag.
R85's face sheet includes diagnoses of morbid (severe) obesity due to excess calories and chronic obstructive pulmonary disease.
R85's POS shows an order of BIPAP setting: 16/9 CM (Centimeters) H20 every shift.
On 3/13/24 at 11:06 AM, V2 (DON-Director of Nursing) stated, It should be contained and stored in a plastic bag for infection control purposes, which includes oxygen tubing, nasal cannula, masks for nebulizers, and CPAP and BIPAP machines. The tubing for these machines should also be dated.
Facility's policy titled Respiratory Therapy Equipment Use (7/28/23) shows: It is the facility's policy to ensure that oxygen and nebulizer equipment use is compliant with the acceptable standards of practice. Procedures: 1. All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. 2. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a PRN (As Needed) basis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess residents for self-administering medications an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess residents for self-administering medications and obtain physician orders to have medication stored in resident rooms. This applies to 4 out of 4 residents (R28, R32, R66 and R75) reviewed for self-administration of medications in a sample of 31.
1. R75's admission Records documents she was admitted to the facility on [DATE]. Diagnoses includes metabolic encephalopathy, multiple sclerosis, seizures, and chronic kidney disease with dependence on renal dialysis.
On 3/12/2024 at 11:04 AM, R75 had a medication cup full of pills. R75 said around 9:30 AM, she told the nurse she was not feeling well and will take her medication later. R75 said the nurse left her medication on her bedside table so she can take it later.
On 3/12/2024 at 11:22 AM, V13 (RN-Registered Nurse) said she attempted to administer R75's medications around 9:30 AM. She said the medications that were in the medication cup were Ascorbic Acid 500 mg (milligrams), Carvedilol 12.5 mg, Colace 100 mg, Tecfidora oral capsule delayed release 240 mg, Divalproex Extended Release 250 mg, Eliquis 2.5 mg, Folic Acid 1 mg, Multivitamin, Renvela 800 mg and Sodium Bicarbonate 325 mg (2 pills). She said there were 11 pills in the cup. V13 said she left the medication by R75's bedside table because resident said she will take it later. V13 went to R75's room and counted and verified that there were 11 medications in the cup she left by R75's bedside table.
On 3/12/2024 at 12:00 PM, review of R75's March 2024 POS (Physician Order Form) showed there is no order for R75 to self-administer medication. Review of assessments in the EMR (Electronic Medical Records) showed R75 does not have a Self-Administration Assessment. Self-Administration of medication assessment and order were obtained during Survey.
On 3/14/2024 at 10:15 AM, V2 (DON-Director of Nursing) said she expects nurses not to leave medication at bedside because of safety concerns and to make sure that resident took the medication.
4. On 3/12/24 at 11:08 AM, R66 was observed in bed in his room. R66 had a bottle of Nyamc 100, 000 Unit/Gram (Nystatin Topical Powder) on his bedside dresser. R66 said the powder belonged to him and he uses it.
R66's current Physician Order Sheet (POS) shows order for Miconazlole Powder to apply transdermally. R66 did not have an order for Nystatin Powder or order to self-administer medications. R66's current care plan was reviewed; R66 was not care planned to self-administer medications.
On 3/14/24 at 10:19 AM, V2 (DON) said residents would need to be assessed to see if they are capable of self-administering medications; after assessment, there needs to a physician order placed and it would be implemented in the resident's plan of care.
Facility's policy titled Self-Administration of Medication (7/28/23) shows: Procedures: 1. The IDT (Inter-disciplinary Team) will assign a staff to evaluate a resident's ability to safely administer medication. A Self-Administration Evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. 3. The nurse on duty will document administration of medication in the MAR (Medication Administration Record). 4. The medication will be administered by the resident. 5. The resident's ability self-administer medication will be assessed regularly by the facility to coincide with the MDS (Minimum Data Set) assessment or any notable change in status.
2. On 3/12/24 at 10:18 AM, R28 was lying in his bed. On top of his bedside table there was an opened Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler. R28 stated, The nurse brought it to me this morning and left it here. The nurse usually leaves it for me to take it and then leaves. He doesn't watch me. No one taught me how to do it. I already know how to take the inhaler.
R28's POS (Physician Order Sheet) shows an order for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG (Micrograms)/ACT-2 inhalations, inhale orally two times a day for shortness of breath. There was no order by the physician for the medication to be at the bedside. R28's electronic medical record was reviewed. There was no self-administration of medication assessment form.
3. On 3/12/23 at 10:40 AM, R32 was not in her room. On her end table there was a bottle of eye drops. On the label it shows Dextran 70, 0.1% Polyethylene Glycol 400, Povidone, and Tetrahydrozline HCL 0.05%. It was also noted to be in her bedroom on 3/13 and 3/14/24. On 3/14/24 at 11:28 AM, R32 who is only Spanish speaking was only able to tell surveyor that the medication belonged to her. She was unable to answer any more questions from surveyor.
R32's POS was reviewed. There was no order for the medication and for it to be at the bedside. Review of her electronic medical record shows there was no self-administration of medication assessment form.
On 03/13/24 at 3:17 PM, V2 (DON-Director of Nursing) stated, I think there's only resident here who can self-administer. They must have a physician's order for them to self-administer and have medications at the bedside. There should be a self-administration of medication assessment form and the nurse is to educate them and have the resident demonstrate how to use a medication to see if it's safe.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to secure a resident's oxygen cylinder. This applies to 5 of 5 residents (R2, R28, R32, R58, R110) reviewed for oxygen in a samp...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to secure a resident's oxygen cylinder. This applies to 5 of 5 residents (R2, R28, R32, R58, R110) reviewed for oxygen in a sample of 31.
The findings include:
On 3/14/24 at 11:30 AM, surveyor went to R28 and R58's room. R28 was lying in bed and R58 was being provided care by V18 (CNA-Certified Nursing Assistant). In between their bed and behind R28's wheelchair, there was a medium size oxygen cylinder on the floor that was unsecured. R28 was unsure of how long the oxygen cylinder was unsecured on the floor. When surveyor brought it to V18's attention, V18 stated, I didn't put it there. The oxygen tank should always be in a carrier. That's a big no no. I will find out who did that and I will try to find the carrier for that oxygen tank. I will take care of it now.
On 3/14/24 at 11:35 AM, V17 (RN-Registered Nurse) stated, The portable oxygen tank should be in a carrier or bag behind the wheelchair. It should be secured when it's on the floor. It will most definitely combust if it falls and it will hurt the residents.
R28 and R58's room is in between R32's room who has her own private room and R2 and R110's room, who both share a room. If R28's oxygen tank falls, it can cause a combustion which can put R58, R32, R2 and R110 at risk
R28's face sheet shows diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Oxygen 2 L (Liters)/ Minute via nasal cannula to maintain oxygen saturation level equal or above 92% every shift.
Facility's policy titled Oxygen Storage (7/28/23) shows: Policy Statement: It is the policy of the facility to store oxygen safely and properly. Procedures: 1. Restrain or secure oxygen tanks at all times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
.
Based on observation, interview & record review, the facility failed to place a thermometer in resident refrigerators, complete temperature logs, remove undated and expired items and keep refrigerat...
Read full inspector narrative →
.
Based on observation, interview & record review, the facility failed to place a thermometer in resident refrigerators, complete temperature logs, remove undated and expired items and keep refrigerators clean.
This applies to 5 of 5 residents (R28, R32, R85, R90 and R110) in a sample of 31.
Findings include:
1. On 3/12/24 at 11:55 AM R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator. V16 (CNA-Certified Nursing Assistant) witnessed these observations and agreed that there is no temperature log on the refrigerator and no thermometer inside. The refrigerator contained following food with no date:
1. Sandwich in ziplock bag - No date
2. Cups (2) with cucumber salad dated 3/7/24
3. Steirofoam box with rice - no date
4. Stierofoam box with pureed beans - no date
5. Ziplock bag with cheese - no date
On 3/13/24 at 2:00 PM, R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator.
On 3/14/24 at 9:00 AM, R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator.
On 3/14/24 at 9:15 AM, V12 (LPN-Licensed Practical Nurse) stated, all refrigerators must have a thermometer to monitor the temperature inside the fridge so that the food remains edible. V12 stated, all food in the refrigerator must have an expiry date on it and all expired items must be discarded.
On 3/14/24 at 10:20 AM, V2 (DON-Director of Nursing) stated, refrigerators need temperature logs to maintain the right temperature, so that food inside is preserved and edible. V2 (DON) stated, the refrigerator temperatures are checked and logged by the housekeeping staff. V2 stated, undated food must not be left in the refrigerator.
On 3/13/24 at 12:30 PM, V1 (Administrator) stated, all refrigerators must have a temp log outside the refrigerator. V1 (Administrator) stated, all food inside the refrigerator must be dated and that any food that is not dated, must be thrown away because it cannot be determined how old the food is.
2. On 3/12/24 at 10:18 AM, R28's refrigerator was inspected. There was no thermometer inside and there was no temperature log. Inside the refrigerator, there was bread, coke, sausage, mustard, and a plastic container with an unknown substance that was not labeled or dated. Inside the refrigerator, there were food stains. R28 stated, They (Staff) are supposed to take temperatures of the fridge, but I've never seen them.
3. On 3/12/24 at 10:40 AM, R32 was not in her room. Inside her fridge, there were tortillas, an onion, and one lemon. Her temperature log that was in a plastic sleeve taped to the side of the refrigerator was missing dates for 1/1, 1/8, 3/2-3/6, 3/8-3/9, 3/11-3/12/24.
4. On 3/12/24 at 10:52 AM, R110 was lying in bed. Inside R110's fridge, there was no thermometer. Inside there was yogurt and milk. Her refrigerator did not have a temperature log posted on her fridge. R110 was unaware if the staff checks the temperature of her refrigerator.
5. On 3/12/24 at 11:45 AM, R85 was not in her room. The refrigerator temperature log was missing dates for 1/1, 1/8, 1/13-1/15, 1/22, and 1/29 to 1/31. For the month of February, they were missing dates for 2/1 to 2/4/24 and 2/6 to 2/28/24. There was nothing completed for the month of March. Inside R85's fridge consisted of ½ pint cartons of reduced fat milk. Two cartons expired on 3/2/24, one expired on 3/9/24, one expired on 3/11/24, and the last one expired on 3/12/24. Inside, there was half of a sandwich, soda, pudding, and bbq (Barbeque) sauce.
On 3/12/24 at 1:48 PM, V2 (DON-Director of Nursing) stated, Housekeeping and the resident's assigned guardian angels (Staff) are supposed check the residents' personal refrigerators. Every fridge should have a thermometer and log sheet.
On 3/12/24 at 2:04 PM, V1 (Administrator) stated, Housekeeping is supposed to do the refrigerator temperature log sheets. There should be thermometers in all resident refrigerators. They need to remove the expired items and they should be discarding the food items if there is no date. They also should clean the refrigerators if it's dirty.
Facility policy 'Refrigerator and Resident Appliance Maintenance Service' dated 7/28/23 showed, 1. resident appliance eg. refrigerators are safe, clean and operable at all times. a. Refrigerator in resident room . 2. c. Temperature is maintained below 41*F (Fahrenheit) and above 32*F using a thermometer with +/- 3 degrees temperature variance. d. Proper labeling, storage and disposition of food items. e. Ensure proper dating and disposition of outdated food items including food brought by family and resident from the outside.
Facility policy 'Food from the Outside Policy' dated 7/28/23 showed, 1) All food brought by visitors and family members from outside of the facility will be labeled with the date it was brought to the facility . 3) After 3-5 days, these food items will be discarded. 4) All undated food items will be discarded to ensure safety of the residents.
Sept 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow a resident's plan of care for transfers for one of three res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow a resident's plan of care for transfers for one of three residents (R1) reviewed for transfers on the sample list of three. This failure resulted in R1's foot getting stuck on the front of R1's wheelchair and R1's foot fracture.
The findings include:
R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy, fracture of right tibia, end stage renal disease, benign prostatic hyperplasia, and atrial fibrillation.
R1's MDS (Minimum Data Set) dated May 26, 2023, showed R1 was cognitively intact. The MDS shows R1 required extensive assistance of facility staff for transfers between surfaces.
R1's ADL (Activities of Daily Living) care plan dated November 17, 2022, showed, [R1] has an ADL self-care performance deficit and impaired mobility related to cerebral palsy, end stage renal disease, coronary artery disease, atrial fibrillation, anemia, and fracture of shaft of right tibia. The care plan continued to show multiple interventions dated August 22, 2023, including, [R1] requires extensive assist times two staff participation with transfers using [mechanical stand assist lift].
R1's x-ray dated August 25, 2023, at 6:47 PM, showed, .Nondisplaced acute oblique fracture distal diaphysis of the right tibia .
A progress note dated August 25, 2023, at 9:00 PM, by V12 (Registered Nurse) showed, .This writer received results from [radiology company] that resident has a nondisplaced acute oblique fracture distal diaphysis of the right tibia. Resident denies pain or discomfort. Received a new order to send resident to [local hospital] per [V5 (Nurse Practitioner)] .
On September 12, 2023, at 12:12 PM, R1 was sitting in his room at the edge of his bed. R1's right foot was in a controlled ankle motion boot. R1 said he must wear the boot because he broke his foot during a transfer. R1 said a couple weeks ago, a male CNA (Certified Nursing Assistant) picked him up to transfer him. R1 continued to say he informed the CNA he (R1) uses a mechanical stand assist lift. R1 said when the CNA transferred him, R1's foot got stuck and it broke.
On September 13, 2023, at 2:45 PM, V3 (CNA) said he was caring for R1 on August 24, 2023, during the 2:00 PM to 10:00 PM shift, and this was V3's first time caring for R1. V3 continued to say R1 requested to be transferred from the wheelchair to his bed. V3 said he did not know R1's transfer status and did not look up R1's transfer status in the Electronic Medical Record (EMR) prior to transferring R1. V3 continued to say he used a gait belt and did a stand and pivot transfer with R1. V3 said as he was transferring R1, R1's foot got caught on R1's front wheelchair wheel. V3 continued to say when he placed R1 in the bed, R1 screamed out in pain. V3 said he touched R1's foot and R1 yelled in pain. V3 said he notified R1's nurse of the pain. V3 continued to say he knew he should have looked up R1's transfer status in the EMR, but V3 did not have time to look up R1's transfer status prior to transferring R1.
On September 13, 2023, at 4:04 PM, V2 (DON/Director of Nursing) said at the time of R1's fracture, R1 was care planned to be transferred using a mechanical stand assist lift. V2 continued to say on August 24, 2023, V3 should have transferred R1 with another staff member using the mechanical stand assist lift. V2 said facility staff and agency staff can see a resident's transfer status in the EMR.
On September 14, 2023, at 10:19 AM, V10 (Restorative Nurse) said prior to R1's leg fracture, R1 was to be transferred using a mechanical stand assist lift. V10 continued to say the mechanical stand assist lift requires two facility staff to transfer a resident.
On September 13, 2023, at 3:27 PM, V11 (R1's physician) said it was definitely possible R1's improper transfer causing R1's foot to get stuck in his wheelchair caused R1's fracture. V11 continued to say it his expectation facility staff would transfer R1 in the safest manner using the way R1 had been assessed for transfer.
The facility's policy titled Mechanical Lift Transfers dated July 28, 2023, showed, Procedures: . 5. There will always be two staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface .
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to implement care planned fall interventions.
This applies t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to implement care planned fall interventions.
This applies to 1 of 4 residents (R7) reviewed for falls in a sample of 10.
Findings include:
1. R7's admission Record dated 8/9/2023 documents R7 admitted to the facility on [DATE] with diagnoses to include compression fracture of the Thoracic 7-8 vertebra and multiple rib fractures.
R7's Care Plan dated 6/28/2023 documents R7 at high risk for falls with interventions to include to keep his bed in the lowest position.
R7's Fall Incident Report dated 6/29/2023 at 4:55 AM documents R7 found on the floor without the call light activated, reporting to staff he attempted to stand up and fell; he denied striking his head.
On 8/15/2023 at 2:07 PM, V9 (Nursing Assistant) stated at the time she discovered R7 on the floor on 6/29/2023 he was next to his bed and his bed was approximately 2 feet from ground, indicating with her hands the approximate level of the bed at her hip level.
On 8/16/2023 at 9:05 AM V2 (Director of Nursing) stated R7 was identified as high risk and fall precautions were implemented upon admit, including a low bed. V2 stated R7's bed should have been lowered to floor level.
On 8/16/2023 11:45 AM V13 (Medical Director) stated he expects the facility to implement fall precautions per their plan of care. V13 confirmed R7 had many falls prior to admission with evidence of injuries, including healed fractures. V13 stated any one of his falls could have potentially caused an acute exacerbation to any existing injury/strain he had from from previous falls. Many of the radiology reports show the injuries of questionable age, artifact in the films and are inconclusive. V13 stated he did not hit his head when he fell 6/29/2023 and there is no signs of a head injury when he was sent out. I cannot contribute the last fall to the injuries that were last found 6/29/2023.
R7's X-Ray of the Left Ribs with Chest dated 6/18/2023 shows R7 with old healed fractures to ribs 4-7 and 6-8. R7's X-Ray of the Thoracic Spine dated 6/18/2023 documents R7 with a age indeterminate compression fracture of the 7th Thoracic Vertebrae. R7's Trauma Surgeon Note dated 7/1/2023 documents the 7th vertebrae fracture as chronic appearing with an acute component.
R7's Brief Interview of Mental Status dated 6/29/2023 shows a score of 12 indicating R7 has moderate cognitive impairments.
The facility policy Fall Occurrences dated 7/17/23 documents it is the policy of the facility to ensure that residents are assessed for risks for falls, interventions are put in place and those interventions are provided.
Apr 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure urinary drainage bags were concealed in dignity bags for 2 of 24 residents (R12, R31) reviewed for dignity in the sampl...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure urinary drainage bags were concealed in dignity bags for 2 of 24 residents (R12, R31) reviewed for dignity in the sample of 24.
The findings include:
1.) R12's 1/3/23 facility assessment shows she is cognitively intact and requires staff assistance with her activities of daily living. R12's current care plan shows she has an indwelling urinary catheter.
On 4/17/23 at 11:40 AM, R12 was sitting up in her wheelchair in her room. Her urinary drainage bag was hanging on the side of her motorized wheelchair. There was a dignity bag in the back of the wheelchair for the urinary drainage bag to be placed in. R12 stated, That catheter bag should not be hanging here like that, it's supposed to be in the bag. That CNA (Certified Nursing Assistant) (V5) doesn't know what she is doing. At 12:17 PM, R12 was observed on her motorized wheelchair in the front lobby of the facility and her drainage bag was still visible and hanging on the side of her wheelchair.
On 4/18/23 at 11:54 AM, R12 was out in the dining area. Her urinary drainage bag was again hanging on the side of her motorized wheelchair and not in her dignity bag.
2.) R31's 1/2/23 facility assessment shows she is cognitively intact and requires assistance with her activities of daily living. R31's current care plan shows she has a suprapubic urinary catheter.
On 4/18/23 at 12:00 PM, V5 (CNA) brought R31 out of her room into the dining area where other residents are present. R31's urinary drainage bag was hanging on the side of her wheel chair and not in a dignity bag. At 12:01 PM this surveyor asked V5 if the facility uses privacy bags for residents catheter bags and she responded, Yes we do, I thought the other CNA had put the catheter in the bag.
The facility's Privacy and Dignity policy revised on 7/28/22 states, It is the facility's policy to ensure the resident's privacy and dignity is respected by the staff at all times. 4. Urine bags will be covered with the use of privacy bags.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a residents room was clean, comfortable, and ho...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a residents room was clean, comfortable, and homelike after a room change for 1 of 24 residents (R62) reviewed for homelike environment in the sample of 24.
The findings include:
On 04/17/23 at 09:48 AM, R62's door (room [ROOM NUMBER]-1) had a sign indicating contact isolation. R62 was in bed in her room sleeping. The bed had crumbs of food/debris on the bed frame. The dresser (located at the foot of the bed) had pillows, towels, and other linens is disarray on top of it. The nightstand located next to the dresser had a wash basin filled with miscellaneous resident items and resident care equipment piled on top of it. The floor contained debris that crunched under the feet of this surveyor and random dirty tissues and food garbage. There was a mattress in a plastic bag against one wall, and an air mattress rolled up in a plastic bag and the machine for the air mattress on the floor against another wall. V14 Certified Nursing Assistant said she was not sure what all the stuff in the room was. V14 said R62 had just moved to this room a few days ago and it looked like she wasn't unpacked. V14 said she wasn't working over the weekend and this stuff was all here this morning.
On 04/18/23 at 09:07 AM, R62 was sitting up in bed eating breakfast. R62 said I don't know what all this is. Well I've had worse mess I guess so I didn't complain I don't think I've seen anyone in here cleaning since I've been in this room.
On 04/18/23 09:20 AM, V6 Licensed Practical Nurse said R62 recently went back on hospice. V6 stated I think that is the supplies from hospice in her room. I'm not sure if she is in a hospice bed or not and still needs to be switched over. Yes the floor is dirty, I'll call housekeeping, and call the hospice company.
On 04/19/23 at 09:49 AM, V2 Director of Nursing said the expectation when a resident has room change is that the resident should be unpacked and settled into the room and the room should be clean.
R62's Census list shows R62 moved to room [ROOM NUMBER]-1 on 4/12/23 (4 days prior to surveyor's first observations of room).
The facility's General Housekeeping Policy dated 7/28/22 shows the facility will ensure that the facility and resident rooms will be clean, orderly and sanitary through housekeeping services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a urinary catheter was maintained in a manner to prevent infection for 1 of 8 residents (R272) reviewed for catheters i...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure a urinary catheter was maintained in a manner to prevent infection for 1 of 8 residents (R272) reviewed for catheters in the sample of 24.
The findings include:
On 04/17/23 at 09:28 AM, R272 was in bed with his urinary catheter tubing and drainage bag was on the floor under the bed. The tubing contained pale yellow urine with sediment.
On 04/18/23 at 9:09 AM, R272's urinary catheter tubing was coming from resident and draped upward over the bed rail. The urine in tubing was backed up and unable to go up the tube to drain into the bag. R272's urinary catheter bag was directly on the floor next to the bed.
On 04/18/23 at 9:09 AM, V6 Licensed Practical Nurse said the catheter tubing shouldn't be over the rail of the bed because the urine can't flow properly which could cause infection and catheter bags shouldn't be on the floor for the same reason.
R272's Care Plan shows Please position catheter bag and tubing below the level of the bladder.
The facility's Indwelling Catheter Policy dated 7/28/22 shows indwelling catheter bag will always be positioned below the bladder region to prevent backflow.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist a resident and resident representative with dis...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist a resident and resident representative with discharge planning. This applies to 1 of 23 residents (R94) reviewed for social services/discharge planning in the sample of 24.
The findings include:
On April 17, 2023 at 2:03 PM, R94 stated, he doesn't know why he is still here (at the facility). He doesn't get to see his parents or his daughter. He just lays around doing nothing.
R94 is on the locked memory care unit.
R94's electronic medical record (EMR) shows, he was admitted to the facility on [DATE]. He is currently [AGE] years old.
R94's Minimum Data Set, dated [DATE] shows, he is cognitively intact. The same assessment shows he requires supervision only for all of his ADL's (activities of daily living) and he walks independently.
On April 19, 2023 at 9:39 AM, V13 R94's POA (power of attorney) stated, no one is helping him get his brother (R94) disability so they can discharge him somewhere that is better for him. My dad and I filled out the forms and he was denied. We were going to appeal and then my dad passed away. My mom passed away a week after R94 was admitted to the facility. I have asked V12 Social Services and he tells me to go to the social security office. I go there and they ask why I am filling out the paperwork and not the facility or at least helping with the paperwork. I can't afford a lawyer to help me. I don't know all the information that they need because he is at the facility. He stated, he doesn't know what to do and no one is helping him, he keeps getting the run around.
On April 19, 2023 at 9:00 AM, V12 Social Services stated, R94's dad was taking care of him and then he came here to the facility. His dad was still managing everything and trying to get him disability so he could be discharged . His dad passed away and now it is on his brother. The plan was to send him to a supportive living here in town. We are just waiting for his disability.
The facility provided R94's social security administration retirement, survivors and disability insurance important information dated March 1, 2021 (2 years ago). The document is filled out by R94's dad. There is no response documented on it. The facility did not provide any more information about the final decision or if an appeal was actually done.
R94's progress notes dated January 8, 2021 (2 years ago) shows, Father called today and asked how resident was doing mentally. Resident seems to be having better conversations with family. The writer did emphasize we can continue to pursue intermediate psych facility that runs groups in the areas of social skills, substance abuse, med mgmt (management), money mgmt, etc.
R94's progress notes dated January 15, 2021 (2 years ago) shows, Resident states he wants to discharge home. When writer (V12 Social Services) asked him what address he had chosen he did give me an accurate address. When I informed his father of resident's progress he acknowledged improvement .
R94's progress notes dated June 7, 2021 (2 years ago) shows, This writer (V12 Social Services) met with the resident at approx. 1 pm. We talked about discharge and I mentioned his Dad was working diligently to help him get SSI (social security income) benefits. His dad is very supportive of resident's goals. I also explained what local supportive living environment can provide. Resident smiled quite brightly at the prospect of having an apartment at local supportive living. About an hour later he did recall the conversation and asked, So if I get SSI I can discharge to local supportive living? This writer replied yes, You would be a good candidate and resident for local supportive living.
R94's progress notes dated December 11, 2022 shows, Resident anxious today. He is known to have panic attacks. NP (nurse practitioner) and this writer (V12 Social Services) encouraged resident to match up his goals with that of his brother and father. Brother is very supportive of resident. However there is no one home during the day. Resident has a hx of binge drinking when left alone . Resident understands as well, that his family has applied for social security disability income. His panic attack seems to end within 5-10 minutes.
R94's EMR does not show anything further about discharge planning or whether social security income has been applied for.
R94's progress notes show, the facility sent referrals to intermediate psych facility's in 2020 but nothing since or more recent.
On April 19, 2023 at 10:12 AM, V12 Social Services stated, he thought the brother had appealed for the social security disability income and they are just waiting for it to come in then R94 can be discharged . He has not done anything with it. R94's dad was doing it and once he passed away it has stalled out.
R94's care plan date initiated June 7, 2021 shows, Focus: R94's discharge potential and discharge planning needs have been assessed by the IDT (interdisplinary team). Due to my complex medical history/diagnosis, I require considerable care and may require longterm services in a SNF (skilled nursing facility). Interventions: Continue to assess my motivation for discharge and potential for a safe discharge. Provide care to enable R94 to function at the most practical level and support enhanced adjustment towards residence in a homelike environment. Provide R94 and/or family with community resources as needed/requested. Referral information provided for: local Supportive living.
The facility's discharge planning and instructions last revised January 6, 2023 shows, Policy Statement: It is the policy of the facility to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge on ce a discharge order is obtained from the resident's attending physician. Procedure: 1. Discharge planning shall be initiated by the facility on resident admission and re-evaluated quarterly. 3. Social Services shall evaluate each resident's discharge planning potential in collaboration with the facility's interdisciplinary team e.g. nursing, therapy, dietary and attending physician. 4. Social Services shall help coordinate resident discharge potential and appropriateness taking into consideration the following but not limited to key factors; a. Health and clinical stability for discharge in a less structured setting, b. Resident cognitive abilities, behavior and functional status, c. Setting where the facility will be discharged e.g. home; another nursing facility; assisted/supportive living facility, d. Adequate family and/or responsible party support system, e. Availability of community support and resources, f. Health support needed and available e.g. home health services. 8. Social Services shall facilitate referrals to appropriate community agencies e.g. home health services; meals on wheels, etc.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure the required Personal Protective Equipment (PPE) was worn during resident care for 1 of 24 residents (R31) reviewed for ...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to ensure the required Personal Protective Equipment (PPE) was worn during resident care for 1 of 24 residents (R31) reviewed for infection control in the sample of 24.
The findings include:
R31's 1/2/23 facility assessment shows she is cognitively intact and requires assistance with her activities of daily living. R31's active care plan initiated on 12/6/22 shows she has a suprapubic urinary catheter and is on enhanced barrier precautions due to her having a suprapubic catheter.
On 4/17/23 at 10:56 AM, V5 (Certified Nursing Assistant/CNA) was inside of R31's room getting her dressed and providing care to assist her to get up for the day and out of bed. V5 was wearing gloves to dress R31 and handle her indwelling urinary catheter bag but she did not have a gown on. At 11:07 AM, V5 (CNA) and V4 (Wound Care Nurse) used the mechanical lift and transferred R31 into her wheelchair, neither staff had gowns on.
There was a sign posted outside of R31's doorway indicating she is on enhanced barrier precautions and indicated staff need to use a gown and gloves when dressing, bathing turning, transferring, and when providing central cares.
On 4/18/23 at 8:10 AM, V6 (Licensed Practical Nurse/LPN) said if staff are providing direct care (turning, dressing, transferring) to residents on enhanced barrier precautions gowns and gloves should be worn.
On 4/18/23 at 10:17 AM, V4 (Wound Care Nurse) said when staff are providing care to residents on enhanced barrier precautions they should wear a gown and gloves.
On 4/18/23 at 12:01 PM, V5 (CNA) said she was not aware she was supposed to wear gowns when providing care to residents with enhanced barrier precautions but she knows now.
The facility's Enhanced Barrier Precaution policy revised on 7/14/22 states, The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of infectious organisms. EBP will be used for any resident in the facility with: an open wound/s, has indwelling medical devices e.g. central line, urinary catheter. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug-resistant organisms) to staff hands and clothing. Examples of high contact resident care activities requiring gown and glove use among residents that trigger EBP use include: a) dressing b) bathing/showering c) transferring d) providing hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer both pneumonia vaccines (pneumococcal conjugate vaccine [PCV13...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer both pneumonia vaccines (pneumococcal conjugate vaccine [PCV13] and Pneumococcal polysaccharide vaccine [PPSV23]) for 3 of 5 residents (R12, R26 and R272) reviewed for vaccines in the sample of 24.
The findings include:
1. R12's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE]. The facility's Immunization Report provided on 4/18/23 showed she received the PCV13 vaccine on 2/17/22 and did not receive the PPSV23 vaccine.
2. R26's face sheet shows he is [AGE] year old male admitted to the facility on [DATE].
The facilities Immunization Report provided on 4/18/23 showed R26 received the PCV13 vaccine on 2/18/22 and did not receive the PPSV23 vaccine.
On 4/18/23 at 1:04 PM, V3 (Infection Control Nurse) said she thought after receiving the PCV13 vaccine the resident had to wait 5 years to receive the PPSV23 vaccine.
3. R272's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE]. R72's Immunization Report shows no documentation recorded for the pneumonia vaccine.
On 4/18/23 at 1:04 PM, V3 (Infection Control Nurse) said pneumoccocal vaccines should be offered on admission. She is not sure if R272 has received his pneumoocoocal vaccines. R272 is a veteran and she reached out to the VA (Veteran Affair) clinic on 4/11/23 and has not followed back up with them.
On 4/19/23 at 10:15 AM V3 said R272 consented to receive to his pneumococcoal vaccine.
The facilities Pneumococcal Vaccination Policy revised 10/31/22 states, It is the policy of the facility to offer and administer pneumococcal vaccinations to each resident who has not received immunization prior to or upon admission, unless otherwise contraindicated or the resident or responsible party has refused the vaccine. 8. For adults who require pneumatically vaccination, if they have previously received PCV13 without PPSV23 then (PCV15 or PCV20 is not recommended); a. For adults 65 years and older, PPSV23 should be given at least one year after PCV13 to complete the vaccination series.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Illinois facilities.
- • 29% annual turnover. Excellent stability, 19 points below Illinois's 48% average. Staff who stay learn residents' needs.
Concerns
- • 25 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Grove Of Fox Valley,The's CMS Rating?
CMS assigns GROVE OF FOX VALLEY,THE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Grove Of Fox Valley,The Staffed?
CMS rates GROVE OF FOX VALLEY,THE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 29%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Grove Of Fox Valley,The?
State health inspectors documented 25 deficiencies at GROVE OF FOX VALLEY,THE during 2023 to 2025. These included: 1 that caused actual resident harm and 24 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Grove Of Fox Valley,The?
GROVE OF FOX VALLEY,THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LEGACY HEALTHCARE, a chain that manages multiple nursing homes. With 158 certified beds and approximately 126 residents (about 80% occupancy), it is a mid-sized facility located in AURORA, Illinois.
How Does Grove Of Fox Valley,The Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, GROVE OF FOX VALLEY,THE's overall rating (4 stars) is above the state average of 2.5, staff turnover (29%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Grove Of Fox Valley,The?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Grove Of Fox Valley,The Safe?
Based on CMS inspection data, GROVE OF FOX VALLEY,THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Grove Of Fox Valley,The Stick Around?
Staff at GROVE OF FOX VALLEY,THE tend to stick around. With a turnover rate of 29%, the facility is 17 percentage points below the Illinois average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 14%, meaning experienced RNs are available to handle complex medical needs.
Was Grove Of Fox Valley,The Ever Fined?
GROVE OF FOX VALLEY,THE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Grove Of Fox Valley,The on Any Federal Watch List?
GROVE OF FOX VALLEY,THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.