Grove of Fox Valley,the

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident identified as dependent on for ADLs (Activities of Daily Living) was protected from sustaining burn injuries. This applies to 1 of 3 residents (R1) reviewed for resident injuries in the sample of 3. This failure resulted in R1 being transferred to the local emergency room on July 7, 2026 and then was transferred to the regional specialty burn center on July 8, 2026. R1 was admitted to the regional specialty burn center from July 8 through July 10, 2026 with 3% mixed thickness burns on the anterior trunk and left thigh.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident dependent on staff for all ADLs (Activities of daily Living), from obtaining full thickness burns on the left side of her torso and partial thickness burns that extended from left upper back to top of the left thigh. This applies to 1 of 3 residents (R1) reviewed for wound care in the sample of 5. This failure resulted in R1 being transferred from the facility to the local emergency room on March 22, 2026, and then transferred to the regional specialty burn center. R1 was admitted to the regional burn center from March 23 through March 26, 2026, with 3% full thickness burns to the left abdomen/flank area with partial thickness burns surrounding the 2 areas of full thickness burn wounds from the left upper back to the left upper thigh.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate the circumstances surrounding an injury of unknown origin, in accordance with facility policy, when a resident dependent on staff assistance for all ADL's (Activities of Daily Living) sustained a burn injury to the left side of her body. This applies to 1 of 3 residents (R1) reviewed for wounds in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain urology recommendations for catheter changes, failed to prevent urinary tract infection, failed to change a catheter when needed, and failed to complete comprehensive assessment for indication of catheter use for residents with indwelling urinary catheter. This applies to 2 of 3 residents (R2 and R3) reviewed for catheter use in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement hand hygiene, wear PPE (personal protective equipment) when rendering care and handling linen. This applies to 5 of 5 (R59, R75, R22, R27, and R66) residents reviewed for infection control in sample 25.

Inspectors wroteBased on interview and record review the facility failed to have a process in place to ensure accuracy of a resident's personal blood glucose monitoring device and failed to accurately write parameters for a resident's blood pressure medication. This applies to 2 of 2 (R9 and R133) residents reviewed for quality care in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to properly maintain a venous access device. This applies to 1 of 1 residents R94 reviewed for venous access devices in a sample of 25.

Inspectors wroteBased on interview and record review the facility failed to prevent a significant medication error. This applies to 1 of 1 residents R133 reviewed for significant medication errors in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for residents that are dependent on staff assistance with activities of daily living (ADLs). This applies to three of seven residents (R1, R2, and R3) reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that blister packs containing controlled medications are maintained intact to ensure safe and effective use of the medications. This applies to 5 of 5 residents (R23, R49, R52, R81 and R103) reviewed for controlled medications in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order to obtain a referral for a Corneal Specialist. This applies to 1 of 1 resident (R77) reviewed for vision services in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized mattress for a resident with worsening acquired pressure injury wound in accordance with wound care practitioner recommendation and their policy. This applies to 1 of 4 residents (R54) reviewed for pressure injury wounds in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that interventions were applied to provide comfort and prevent further worsening of resident's contracted hands. This applies to 2 of 3 residents (R17 and R41) reviewed for range of motion in the sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a diet that includes the resident's diet preference. This applies to 1 of 1 resident (R137) reviewed for dining in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to follow their policy for antibiotic stewardship to ensure residents received the appropriate antibiotic for an infection. This applies to 2 of 2 residents (R15 and R32) reviewed for antibiotic use in the sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents for self-administering medications and obtain physician orders to have medication stored in resident rooms. This applies to 4 out of 4 residents (R28, R32, R66 and R75) reviewed for self-administration of medications in a sample of 31. 1. R75's admission Records documents she was admitted to the facility on [DATE]. Diagnoses includes metabolic encephalopathy, multiple sclerosis, seizures, and chronic kidney disease with dependence on renal dialysis. On 3/12/2024 at 11:04 AM, R75 had a medication cup full of pills. R75 said around 9:30 AM, she told the nurse she was not feeling well and will take her medication later. R75 said the nurse left her medication on her bedside table so she can take it later. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure a resident's oxygen cylinder. This applies to 5 of 5 residents (R2, R28, R32, R58, R110) reviewed for oxygen in a sample of 31.

Inspectors wroteBased on observation, interview & record review, the facility failed to place a thermometer in resident refrigerators, complete temperature logs, remove undated and expired items and keep refrigerators clean. This applies to 5 of 5 residents (R28, R32, R85, R90 and R110) in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to follow its advance directives policy. This applies to 2 of 10 (R40 & R14) reviewed for advance directives in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure R24 was free from physical restraint. This applies to 1 of 1 resident (R24) reviewed for physical restraints in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to assist with discharge planning. This applies to 2 of 3 residents (R106 and R14) reviewed for discharges in a sample of 31.

Inspectors wroteBased on observation interview and record review the facility failed to utilize communication tools for the use of residents and staff. The facility failed to provide written information in the residents preferred language. This applies to 3 of 3 residents (R21, R104 and R114) reviewed for communication in a sample size of 31.

Inspectors wroteBased on interview and record review, the facility failed to monitor lab value medications for cardiac/anti-rhythmic (high risk) medications. This applies to 1 of 1 resident (R43) reviewed for high risk medications in a sample of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to change a loose and soiled midline dressing. This applies to 1 out of 2 residents (R17) reviewed for peripheral lines in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately contain respiratory equipment. This applies to 3 of 3 residents (R20, R37, R85) reviewed for oxygen in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to follow a resident's plan of care for transfers for one of three residents (R1) reviewed for transfers on the sample list of three. This failure resulted in R1's foot getting stuck on the front of R1's wheelchair and R1's foot fracture.