Health inspection·April 28, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 timely incontinence care for residents that are dependent on staff assistance with activities of daily living (ADLs). This applies to three of seven residents (R1, R2, and R3) reviewed for incontinence care. Residents Affected - Few The finding includes: R1, a [AGE] year-old, admitted on [DATE]. R1's diagnoses included diabetes mellitus, other disease of anus/rectum, ulcerative colitis, major depression, neuropathy, and fractures of the 4th and 5th thoracic vertebrae. The MDS (Minimum Data Set) dated March 16, 2025, indicates R1 is cognitively intact (BIMS (Brief Interview Mental Status) score of 15/15) and requires staff assistance with ADLs, including incontinence care. The care plan dated March 24, 2025, directs staff to provide incontinence care every two hours and as needed. R2, a [AGE] year-old, admitted on [DATE]. R2's diagnoses included right below-knee amputation, diabetes mellitus, peripheral vascular disease, gastroenteropathy. The MDS dated [DATE], shows R2 is cognitively intact (BIMS score 15/15) and dependent on staff for hygiene and incontinence care. The care plan dated April 25, 2025, directs incontinence care every two hours and as needed. R3, a [AGE] year-old admitted on [DATE]. R3's diagnoses included diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and diarrhea. The MDS dated [DATE], documents R3 as severely cognitively impaired and requiring extensive staff assistance for ADLs, including incontinence care. The care plan dated April 4, 2025, instructs provision of incontinence care every two hours and as needed. On April 25, 2025, at 11:00 A.M., R1 was observed with a saturated incontinence brief. V8 (CNA), at this time provided incontinence care to R1. V8 stated that incontinence care for R1, R2, and R3 (roommates) was delayed due to V7 (Certified Nursing Assistant /CNA) leaving the facility for personal reasons. V8 reported that incontinence care was subsequently provided to R2 at 10:30 A.M. and to R3 at 10:45 A.M. Both R2 and R3 were also found to have soaked incontinence briefs. During this time of observation, R1 stated that the last incontinence care and brief change were provided by V9 (CNA) during the night shift around 5:00 A.M. R2 and R3 similarly reported that their last incontinence care was also performed by V9 at approximately 5:00 A.M. On April 25, 2025, at 5:45 P.M., V9 validated that she had provided incontinence care for R1, R2, and R3 between 5:00 A.M. and 5:30 A.M. that morning. At 5:10 P.M. on the same day, V7 (CNA) stated that she was assigned to R1, R2, and R3 for the day (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 04/28/2025 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)