Inspection·August 24, 2023

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 have a Physician's order for the care of a PICC (peripherally inserted central venous catheter) and failed to provide PICC insertion site dressing changes and monitoring in accordance with facility policy. Residents Affected - Few This applies to 1 of 3 residents (R24) reviewed for intravenous catheters in the sample of 17. The findings include: On August 21, 2023, at 10:45 AM, R24 was observed with a PICC on the right upper arm. There was a transparent dressing covering the site and the date on the label was unable to be read. R24 stated the PICC line was put in while he was in the hospital and the facility staff had never changed the dressing. R24's face sheet showed R24 was admitted to the facility on [DATE], with multiple diagnoses included osteomyelitis of right foot, cellulitis of the right lower limb, unspecified atrial fibrillation, atherosclerotic heart disease, and chronic kidney disease. R24's MDS (Minimum Data Set) dated August 3, 2023, showed R24 moderately impaired cognition and required extensive assistance with toileting, dressing and bed mobility and limited assistance for transfer, personal hygiene, and locomotion in the wheelchair. On August 21, 2023, at 11:01 AM, V13 (LPN, Licensed Practical Nurse, Wound Nurse) observed R24's right arm PICC line insertion site dressing and V13 stated that she was unable to read the date on the dressing. V12 (RN-Registered Nurse) observed R24's PICC line site on August 21, 2023, at 11:15 AM, and stated the date on the PICC site dressing was unable to be read. V12 stated the night shift usually changes the PICC line dressing weekly. V12 looked through R24's documentation in the EMR (electronic medical record) and stated there is no documentation the PICC line dressing has been changed since R24's admission. On August 22, 2023, at 8:57 AM, V2 (Director of Nursing) stated R24 had no orders for the PICC line dressing and maintenance since admission on [DATE]. R24's care plan dated July 29, 2023, did not include any interventions regarding the care and maintenance of R24's PICC line. R24's Physician order summary dated July 29, 2023, did not include any orders for the care and maintenance of R24's PICC line. The facility's policy for Central Line Care, dated April 2023, showed All PICC line treatments and dressings require a physician order and following the initial 24-hour dressing change an RN or LPN will change the injection cap and the dressing at a minimum weekly or any time the dressing becomes moist, loosened or soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 2 of 8 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 146194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504 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 Based on observation, interview and record review, the facility failed to ensure that oxygen was delivered to a resident at the prescribed dosage. Residents Affected - Few This applied to 1 of 1 resident (R201) reviewed for oxygen in the sample of 17. The findings include: R201's face sheet included diagnoses of chronic obstructive pulmonary disease, unspecified, pulmonary hypertension, unspecified, difficulty in walking, not elsewhere classified, other reduced mobility, displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing. R201's 5 day MDS (Minimum Data Set) dated August 8, 2023 showed that R201 was cognitively intact. R201's POS (Physician Order Sheet) included: May administer 2L (liters) supplemental Oxygen as needed (start date August 1, 2023). R201's care plan revised on August 21, 2023 included that R201 has altered respiratory status/difficulty breathing related to Congestive heart Failure, Chronic Obstructive Pulmonary Disease, Heart Failure. Interventions for the same included supplemental oxygen as ordered by Medical Doctor. On August 21, 2023 at 11:58 AM, R201 was seated in her private room in a wheelchair and was wearing a nasal cannula which was connected to continuous oxygen on the wall. The dial setting of the oxygen was noted at 4.5 L (liters). When asked, R201 stated It should be at 2 liters. R201's assigned nurse V7 (Licensed Practical nurse) was called into the room to view the setting and confirmed the reading. V7 stated I only work as needed here. They told me this morning it is at 3 liters. I wasn't the one who put her on oxygen this morning. She must have put it on herself. R201 then stated that it was a staff member who brought her into the room that put the oxygen on. V7 added that it could be the Therapist who put the oxygen on. On August 22, 2023 at 9:57 AM, V8 (Rehab Tech) wheeled R201 into the room and hooked up R201's nasal cannula to the continuous oxygen on the wall and left. When asked what level the oxygen was set at, V8 stated that he set it at 3 liters and added that he always sets it back at what it was set at prior to taking the resident to therapy. When checked, the oxygen was set at 3L. On August 22, 2023 at 10:02 AM, V9 (Registered Nurse) who was R201's assigned nurse for the day, stated that R201 is on 3L of oxygen. On review of orders, V9 acknowledged that orders showed 2L supplemental Oxygen. On August 23, 2023 at 11:30 AM, V2 (Director of Nursing) stated that the staff should follow Physician orders for oxygen therapy. V2 stated If it 2L then yes it should be 2L. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 3 of 8 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 146194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 perform comprehensive pain assessment and develop an individualized plan of care to manage the resident's pain. Residents Affected - Few This applies to 1 of 3 residents (R300) reviewed for pain management in the sample of 17. The findings include: On August 21, 2023, at 11:03 AM, R300 was in bed, with facial grimacing, and stated she does not feel comfortable, stated her pain score was 7 out of 10. On August 22, 2023, at 10:13 AM, R300 stated her pain goal is 3 out of 10. R300's admission record showed R300 was admitted to the facility on [DATE], with multiple diagnoses including, aftercare following joint replacement surgery (right), presence of artificial left hip joint, diabetes mellitus, long term use of insulin, low back pain, unspecified, and essential hypertension. R300's nursing evaluation dated August 16, 2023, showed R300 is alert and oriented to person, place, time, and situation and requires assistance with ADLs (Activities of Daily Living). R300's care plan for potential for pain, dated August 16, 2023, does not include R300's pain goal, or non-pharmacological interventions. R300's EMR (Electronic Medical Record) does not contain a comprehensive pain evaluation after admission. R300's vital signs summary dated from August 16, 2023, through August 23, 2023, for pain scores showed: August 23, 2023, - 10:02 AM - 6 August 23, 2023, - 12:50 AM - 7 August 22, 2023, - 2:49 PM - 10 August 22, 2023, - 8:58 AM - 7 August 21, 2023, - 9:45 PM - 5 August 21, 2023, - 11:04 AM - 7 August 19, 2023, - 10:37 AM - 8 August 18, 2023, - 10: 52 PM - 7 August 18, 2023, - 2:33 PM - 8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 4 of 8 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 146194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504 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 0697 August 18, 2023, - 11:27 AM - 8 Level of Harm - Minimal harm or potential for actual harm August 17, 2023, - 7:00 AM - 7 Residents Affected - Few On August 23, 2023, at 12:36 PM, V2 (Director of Nursing) reviewed R300's summary pain scores from August 16, 2023 to August 23, 2023. V2 stated while reviewing R300's pain scores, her pain is not well controlled, and they should contact the doctor to reassess pain medication. V2 further stated a comprehensive pain evaluation in the EMR should be completed any time pain is not controlled. The facility's Pain Management policy dated May 2023, showed should reassessment activities identify presence of pain as a new condition for the resident the comprehensive initial pain assessment form will be completed at that time and Strategies for pain management include but are not limited to: .Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as if pain is episodic, continuous, or both .and .Identifying and using specific strategies for preventing or minimizing different levels or sources of pain .and resident goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 5 of 8 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 146194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 25 opportunities with 2 errors, resulting in an 8% medication error rate. Residents Affected - Few This applies to 1 of 6 residents (R300) observed during the medication pass in the sample of 17. The findings include: On August 22, 2023 at 9:11 AM, during medication pass, R300 complained of shortness of breath, feeling tired and wheezing. R300 requested to receive her inhaler. V12 (Registered Nurse) prepared and administered multiple medications to R300, including Albuterol AER HFA (aerosol hydrofluoroalkane) inhaler. V12 administered two puffs/inhalation of the Albuterol inhaler to R300 consecutively without waiting for at least one minute in between inhalations. On August 22, 2023 at 10:01 AM, during medication pass, V12 applied Erythromycin ophthalmic ointment on the skin around R300's eyes. V12 did not pull down R300's lower eye lid to apply the ophthalmic ointment. R300's active order summary report showed following orders dated August 16, 2023, Albuterol Sulfate HFA (hydrofluoroalkane) inhalation aerosol solution 108 (90 base) mcg/act (micrograms/actuation), 2 puff inhale orally every 4 hours as needed for wheezing and Erythromycin Ointment 5 mg/ml, 1 application intraocularly two times a day to apply to lesions thin ribbon. On August 23, 2023 at 10:05 AM, V2 (Director of Nursing) stated that based on the physician order to apply the Erythromycin ophthalmic ointment intraocularly, the nurse should apply the said ophthalmic ointment to R300's lower conjunctival sac by gently pulling down the lower eye lid to create a pocket like opening. According to V2, the physician order should be followed for proper absorption of the Erythromycin ophthalmic ointment. During the same interview, V2 stated that for the Albuterol inhaler, the nurse should wait one minute in between puffs to ensure that the medication settles in the lungs before giving the next puff/dose. On August 23, 2023 at 1:43 PM, V15 (Pharmacist) stated that for the Albuterol inhaler, the nurse should wait one minute in between puffs/inhalation to ensure that the first dose gets absorbed by the lungs. V15 stated that if the Albuterol inhaler was administered consecutively without waiting for at least one minute in between, it does not allow the lungs to fully absorb all the Albuterol medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 6 of 8 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 146194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to serve pureed and mechanical soft diet consistencies to residents with diet orders for the same. Residents Affected - Some This applies to 5 of 5 residents (R1, R7, R11, R27, R99) reviewed for dining in the sample of 17. The findings include: On August 22, 2023 at 11:42 AM, V5 (Cook) was observed preparing pureed meals in the facility kitchen. V5 stated that he is pureeing the lunch meal consisting of Greek marinated chicken and green beans for 2 residents (R1 and R11) based on production sheet. V5 stated that he is serving cream of rice instead of pureeing the rice. During the pureeing process, V5 added three pieces of chicken (about 4 oz each piece) into a blender with minimal amount of broth and pureed the same. The final product appeared granular with uneven texture. V5 put two 4 oz scoops of cooked green beans into another blender and pureed the same with minimal broth and thickener. The final product had small pieces of green beans that were not able to be mashed in between the fingers. Prior to transferring into service bowls, V4 (Dietary Manager) was notified and V4 agreed that these items needed to be pureed more. On August 22, 2023 at 11:55 AM, during meal service in the facility kitchen, V5 (Cook) was noted to serve R7, R27 and R99 a mixture of white rice and wild rice. R7, R27 and R99 diet tickets showed mechanical soft, chopped [meat] consistency. The wild rice had hard pieces of rice grains with outer skins intact. V5 stated that the herbed rice did not come in and therefore he substituted it with the wild rice mixture. On August 22, 2023 at 11:57 AM, V3 (Dietitian) stated that the pureed consistency should be more like baby food with the consistency like apple sauce or mashed potato. V3 stated that she will look into the policy for mechanical soft and report back whether wild rice is allowed. V3 brought back an undated policy titled Dental Soft (Mechanical Soft) which included as follows: This consistency diet is for individuals with limited or difficulty in chewing regular textured food. Generally, the diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. On testing the wild rice pieces, V3 agreed that the consistency was hard. V3 added that anytime a meal item is substituted, a form should be filled out and approval obtained from Dietitian for the substitute item. Policy titled Puree Diet (effective date 1/17/2016) included as follows: Policy: This diet may be used to help provide adequate nutrition to guests with swallowing problems, guest who have problems with chewing due to refusal or pain or guests who are transitioning back to solids following the removal of feeding tube. Procedure: The regular menu is followed and served in smooth puree with no lumps or whole particles. Recipe for both Pureed Greek Marinated Chicken and Pureed [NAME] Beans showed to add gradual amount of liquid or thickener to achieve a smooth, pudding or soft mashed potato consistency. Facility Diet Type Report printed on August 21, 2023 showed that R1 and R11 were on pureed diets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 7 of 8 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 146194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504 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 0805 and R7, R27 and R99 were on mechanical soft, chopped diets. Level of Harm - Minimal harm or potential for actual harm Policy titled Making Menu Substitutions (taken from Dining Service Menu guide, 2022) included as follows: Residents Affected - Some Please be aware that making changes on your menu, whether just one-time substitution or a permanent menu change, requires approval from your consultant Dietitian. A log of substitutions must be kept on file, including what food item(s) was/were substituted, the date, reason for the substitution(s) and what new food item(s) was/were served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146194 If continuation sheet Page 8 of 8