Inspection·March 18, 2025

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 observation, interview, and record review the facility failed to assess, monitor, document, and care plan a resident with a cholecystostomy drain and failed to provide care and services for a resident needing staff assistance for 2 of 4 residents (R2, R4) reviewed for quality of care in the sample of 4. Residents Affected - Few The findings include: 1. On 3/18/25 at 11:06 AM, R4 was sitting up in a wheelchair in her room. R4 had a cholecystostomy drainage bag sitting next to her in the wheelchair. R4 stated she had a gallbladder attack in hospital and the bag is from that. R4 stated there is some drainage into the bag and the nurses drain it. R4 lifted her shirt and showed this surveyor the cholecystostomy incision site on the right side of her abdominal area. R4's incision site had gauze covering the insertion area with the drainage tube coming out. The gauze was covered with a transparent dressing. The gauze had a nickel size dried brownish red area of drainage around the drainage tube. There was no date on either dressing. R4 stated this dressing is from the hospital, no one here has changed it or looked underneath the dressing. V12 (R4's) son was sitting bedside and confirmed that the dressing around the insertion site of the cholecystostomy was the one the hospital put on. On 3/18/25 at 10:07 AM, V6 Licensed Practical Nurse stated R4 has a drain that needs to be emptied and documented once a shift. V6 stated R4's drain has a small amount of golden colored drainage usually. V6 stated she was not aware of dressing change orders or monitoring for the insertion site. On 3/18/25 at 11:31 AM, V2 Director of Nursing stated nurses should be looking and assessing R4's cholecystostomy insertion site to monitor for signs and symptoms of infection. V2 stated there should be orders for dressing changes to the site and if the hospital discharge orders did not contain orders the nurse should reach out to the doctor for orders. R4's face sheet shows R4 was admitted on [DATE] with a diagnosis of calculus of gallbladder with acute cholecystitis with obstruction. R4's admission assessment dated [DATE] shows Does the Resident have surgical drain? NO is marked. R4's Progress Note dated 3/9/25 shows the resident does not have a surgical drain. R4's Care Plan shows R4 is at risk for alteration in skin integrity related to fall, hematoma center forehead, acute displaced fractures of left and right nasal boned, calculus of gallbladder with acute cholecystitis, chole tube, acute kidney injury, respiratory failure. There are no interventions listed for monitoring or care of R4's cholecystostomy drain. (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 03/18/2025 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)