Health inspection·October 24, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 assessment of a resident's surgical wounds and failed to follow physician orders for wound/incision care. Residents Affected - Few This applies to 1 of 3 residents (R2) reviewed for wounds in the sample of 7. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE], and was discharged to the local hospital on April 10, 2023. R2 did not return to the facility. R2 had multiple diagnoses including, malignancy of the vulva, Sjogren syndrome (autoimmune disease), hypogammaglobulinemia (low antibody levels), diabetes, rheumatoid arthritis, polyneuropathy, muscle weakness, unsteadiness on feet, restless legs syndrome, and depression. R2's MDS (Minimum Data Set) dated April 10, 2023, shows R2 was cognitively intact, was able to eat with supervision, required limited assistance with walking, locomotion and personal hygiene, and extensive assistance with bed mobility, transfers between surfaces and toilet use. R2 was occasionally incontinent of bowel and bladder. R2's MDS continues to show R2 had surgical wounds present on admission requiring surgical wound care, and no other skin breakdown. The facility's admission Nursing Evaluation dated April 5, 2023, at 4:50 PM shows: Skin Integrity: Groin: Surgical incision to peri/groin area. Wound edges well approximated with no drainage. JP (Jackson Pratt) drain to right inner thigh. Other: Bruising to right lower abdomen. The facility does not have any further documentation to show the location of R2's surgical wounds/incisions. Furthermore, the facility does not have any documentation of the length, width, and depth measurements, direction, and length of any tunneling and undermining, the appearance of the wound base, any drainage amount or characteristics, or appearance of the wound edges. R2's hospital After Visit Summary dated April 5, 2023, at 12:47 PM shows: When to call your doctor: Temperature > (greater than) 100.4 (degrees Fahrenheit), vulvar/vaginal bleeding that soaks a sanitary napkin every 2-4 hours, yellow (pus-like), green or odorous discharge from vaginal or from the sutures . Additional instructions (daily weights, wound care): You have sutures over your vulva area that will dissolve in about 4-6 weeks. The sutures may open a little so do not be alarmed. If the incision opens, please call. You have small dissolvable sutures with glue over the right and left groin area. Do not scrub the glue off the glue. The glue will gradually crumble off with normal bathing. 1. Please keep your incisions clean and dry. Please check the incisions lines with a mirror a few times a day to ensure it's dry. You should let soapy water run over groin incisions and vulvar (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 3 Event ID: 146194 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 10/24/2023 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)