Health inspection·August 16, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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. Residents Affected - Few 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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145006 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 08/16/2023 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)