Health inspection·January 9, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 provide specialized mattress for a resident with worsening acquired pressure injury wound in accordance with wound care practitioner recommendation and their policy. Residents Affected - Few 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 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 2 of 10 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 01/09/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 3 of 10 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 01/09/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 4 of 10 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 01/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 5 of 10 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 01/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - 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, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 6 of 10 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 01/09/2025 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 0755 or makeshift labels are destroyed in accordance with the medication destruction policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 7 of 10 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 01/09/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to provide a diet that includes the resident's diet preference. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 8 of 10 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 01/09/2025 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 0881 Implement a program that monitors antibiotic use. 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 follow their policy for antibiotic stewardship to ensure residents received the appropriate antibiotic for an infection. Residents Affected - Few 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 9 of 10 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 01/09/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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? . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145006 If continuation sheet Page 10 of 10