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 Page 1 of 2 145652 145652 04/08/2024 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition. We dropped the ball with this one. (R1) had a fall on 3/23/24 and we didn't notify (V10) until 4/2/24. V2 stated grievances can be filed, verbally or in writing, by a resident or resident's family. V2 stated grievances should be resolved as soon as possible. On 4/8/24 at 12:04 PM, V1 Administrator stated he also attended R1's care plan meeting, via phone, on 12/4/23. V1 stated V10 (R1's POA) voiced her concerns about a lack of communication from the facility during the meeting. V1 stated, (V10) did say she wanted to be called immediately if anything happened with (R1), day or night. The facility's Resident Grievance Policy dated 1/2018 showed, It is the policy of (the facility) to address all resident and/or family concerns as quickly as possible and as best as possible . 145652 Page 2 of 2