Health inspection·September 14, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **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 (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 09/14/2023 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)