Inspection visit
Health inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.
Residents Affected - Some
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.
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.
(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 15
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
03/15/2024
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 0554
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 2 of 15
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
03/15/2024
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 3 of 15
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
03/15/2024
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 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 ensure R24 was free from physical restraint.
This applies to 1 of 1 resident (R24) reviewed for physical restraints in a sample of 31.
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 4 of 15
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
03/15/2024
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 0660
Plan the resident's discharge to meet the resident's goals and needs.
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 assist with discharge planning. This applies to 2 of 3
residents (R106 and R14) reviewed for discharges in a sample of 31.
Residents Affected - Few
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 5 of 15
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
03/15/2024
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 0660
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 .
Event ID:
Facility ID:
145006
If continuation sheet
Page 6 of 15
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
03/15/2024
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 utilize communication tools for the use of
residents and staff. The facility failed to provide written information in the residents preferred language.
Residents Affected - Few
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 7 of 15
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
03/15/2024
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 0676
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
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).
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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 8 of 15
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
03/15/2024
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 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.
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 9 of 15
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
03/15/2024
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 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.
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.
Residents Affected - Some
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 10 of 15
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
03/15/2024
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 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
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 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.
Residents Affected - Few
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).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 11 of 15
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
03/15/2024
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
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 appropriately contain respiratory equipment.
This applies to 3 of 3 residents (R20, R37, R85) reviewed for oxygen in a sample of 31.
Residents Affected - Few
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.
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 12 of 15
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
03/15/2024
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 0695
dust and thereby preventing potential problem of respiratory infection.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 13 of 15
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
03/15/2024
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 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Some
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 1/2 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.
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 14 of 15
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
03/15/2024
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 0813
Findings include:
Level of Harm - Minimal harm
or potential for actual harm
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:
Residents Affected - Some
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145006
If continuation sheet
Page 15 of 15
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F660 - Quality of life
Plan the resident's discharge to meet the resident's goals and needs.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
FAQ · About this visit
Common questions about this visit
What happened during the March 15, 2024 survey of GROVE OF FOX VALLEY,THE?
This was a inspection survey of GROVE OF FOX VALLEY,THE on March 15, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GROVE OF FOX VALLEY,THE on March 15, 2024?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.