Health inspection·April 8, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review the facility failed to resolve a grievance/concern verbalized by a resident's POA (power of attorney) for 1 of 3 residents (R1) reviewed for grievances in the sample of 3. Residents Affected - Few The findings include: R1's care plan dated 3/12/24 showed R1 was cognitively impaired due to her diagnosis of dementia. The care plan showed R1 was at risk for falls due to her impaired cognition, impulsivity, weakness and poor safety awareness. A progress note for R1, dated 12/4/23, showed, POA must be notified at time of event of any change in condition or any care item added to the care plan. R1's fall incident report dated 3/23/24 showed R1 sustained an unwitnessed fall in the bathroom. R1 received no injuries from the fall. The report showed V10 (R1's POA) was not notified of R1's fall until 4/2/24. On 4/8/24 at 11:33 AM, V10 (R1's POA) stated, My concerns with a lack of communication from the facility have been going on for months. I have had multiple conversations and sent emails back and forth with (V1 Administrator) about the lack of communication from the facility. We had a care plan meeting, via phone, in December (2023) with (V1 Administrator), (V2 Assistant Administrator), and (V3 Director of Nursing/DON) on the call. I told them then that I was to be notified, day or night, if (R1) has any falls or changes in condition. I get a call on April 2nd (2024) from someone asking me if I knew (R1) had fallen on March 23rd. No one had told me a thing. I had just visited (R1) on Easter and no one said a word. On 4/8/24 at 12:50 PM, V9 Licensed Practical Nurse stated, I review all of the accident and incident reports in the facility. I saw that (R1) had a fall on 3/23/24 but didn't see any documentation that (V10 R1's POA) had been notified of the fall so I called her. (V10) was very upset no one had called her. She went from crying to yelling. She said she was so sick of the lack of communication from us. On 4/8/24 at 11:45 AM, V2 Assistant Administrator stated she attended R1's care plan meeting, via phone, on 12/4/23. V2 stated V10 (R1's POA) expressed her concerns related to a lack of communication from the facility during the meeting. V2 stated, (V10) was upset about the lack of communication. She was upset that she was not notified in real time when things were happening with (R1). That is when she said we are to call her immediately, day or night, if (R1) falls or has a change in (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: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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)