Inspection·November 2, 2023

F 0695 Provide safe and appropriate respiratory care 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 interview and record review the facility failed to ensure a CPAP machine (continuous positive airway pressure machine) was operated as ordered by the physician for 1 of 3 residents (R1) reviewed for CPAP machines in the sample of 3. Residents Affected - Few The findings include: R1's face sheet printed on 11/2/23 showed an admission date of 10/25/23 and diagnoses including but not limited to atherosclerosis of left leg arteries, right side paralysis, heart disease, diabetes mellitus, aphasia (difficulty speaking), and need for assistance with personal care. R1's facility assessment dated [DATE] showed severe cognitive impairment and the use of a CPAP machine. R1's admission progress note dated 10/25/23 stated the physician was notified of the new admit, diagnoses of recent left femoral popliteal bypass surgery, left great toe ulcer, staples to surgical incision to left lower leg, and left groin incision. The note showed orders for lab work to be done in the morning. R1's order summary report showed an order start dated 10/25/23 for: Administer CPAP at night every night shift. R1's medication administration record showed the order was performed as ordered by the night nurse (V6). On 11/1/23 at 3:20 PM, V3 (R1's daughter) stated she arrived at the facility in the afternoon on 10/26 (day after admission). V3 said she noticed R1's CPAP machine on the nightstand and a large jug of fluid next to it. The jug was labeled as hemodialysis fluid (solution used to filter the blood during kidney treatments). V3 said it should have been distilled water. V3 said she opened the CPAP reservoir chamber, and it had an unusual odor similar to vinegar. The chamber had a strange, thick residue inside of it. V3 said she notified a floor nurse (V4) who came to the room and saw the jug. V3 said R1's physician was in the facility, and V4 went to notify him of the situation. On 11/2/23 at 10:15 AM, V4 (Wound Care Nurse) stated she was approached by V3 in the hallway sometime in the afternoon on 10/26 and told there was something not right with R1's CPAP machine. V4 said she looked at the machine with V3. It was half filled with a liquid and there were crystals near the top of the reservoir. V4 said a jug was next to it with a purple label and it was hemodialysis solution. V4 said she immediately notified R1's physician. On 11/2/23 at 10:32 AM, V5 (R1's physician) stated he was notified by V4 in the afternoon on 10/26 that hemodialysis fluid had been administered to R1 in the CPAP machine. V5 said he had been with R1 earlier in the day for the initial assessment and was familiar with him. V5 said he reassessed R1 (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: 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 11/02/2023 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)