Health inspection·April 19, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Fox Valley,the 1601 North Farnsworth Avenue Aurora, IL 60505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Fox Valley,the 1601 North Farnsworth Avenue Aurora, IL 60505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to 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. Residents Affected - Few 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 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Fox Valley,the 1601 North Farnsworth Avenue Aurora, IL 60505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Fox Valley,the 1601 North Farnsworth Avenue Aurora, IL 60505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure 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. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Fox Valley,the 1601 North Farnsworth Avenue Aurora, IL 60505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 7 of 7