Inspection Reports for The Grove Fox Valley
1601 N. Farnsworth, Aurora, IL 60505, Aurora, IL
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 25, 2025
Visit Reason
The inspection was conducted due to concerns about delayed and inadequate incontinence care for residents dependent on staff assistance with activities of daily living.
Complaint Details
The investigation was complaint-related, triggered by concerns from residents' Powers of Attorney about delayed incontinence care and soaked briefs. The complaint was substantiated by observations and staff interviews.
Findings
The facility failed to provide timely incontinence care to three residents (R1, R2, and R3), resulting in soaked briefs and delayed care. Staff shortages and shift changes contributed to the delays, and family members expressed ongoing concerns about the care provided.
Deficiencies (1)
Failure to provide timely incontinence care for residents dependent on staff assistance with activities of daily living.
Report Facts
Residents reviewed for incontinence care: 7
Residents affected: 3
Time of last incontinence care: 5
Time of observed delayed care: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Certified Nursing Assistant (CNA) | Assigned to R1, R2, and R3 but left facility before providing incontinence care. |
| V8 | Certified Nursing Assistant (CNA) | Provided delayed incontinence care to R1, R2, and R3 and reported reasons for delay. |
| V9 | Certified Nursing Assistant (CNA) | Provided last incontinence care to R1, R2, and R3 during night shift around 5:00 A.M. |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, dietary services, and infection control at the Grove of Fox Valley nursing home.
Findings
The facility was found deficient in multiple areas including failure to schedule specialist appointments timely, inadequate pressure ulcer care, insufficient interventions for residents with contracted hands, improper management and accounting of controlled medications, failure to accommodate resident dietary preferences, and failure to follow antibiotic stewardship policies ensuring appropriate antibiotic use.
Deficiencies (6)
Failed to follow a physician's order to obtain a referral for a Corneal Specialist for a resident.
Failed to provide specialized mattress for a resident with worsening pressure injury wound as recommended.
Failed to ensure interventions were applied to provide comfort and prevent worsening of residents' contracted hands.
Failed to ensure accurate and timely accounting of controlled medications and maintain blister packs intact.
Failed to provide a diet that includes the resident's diet preference, specifically gluten-free diet.
Failed to follow antibiotic stewardship policy to ensure residents received appropriate antibiotics for infections.
Report Facts
Residents reviewed: 27
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 2
Medication tablets missing: 1
Medication tablets missing: 1
Medication tablets missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Commented on delay in scheduling corneal specialist appointment and medication accountability |
| V4 | Infection Preventionist Nurse | Discussed antibiotic stewardship and antibiotic timeout process |
| V7 | Dietary Manager | Confirmed resident received non-gluten free dinner roll |
| V9 | Guest Services | Notified dietary department about resident diet concerns |
| V13 | Assistant Director of Nursing | Observed medication cart and controlled medication discrepancies |
| V14 | Registered Nurse | Acknowledged missing medication tablet and incomplete documentation |
| V15 | Registered Nurse | Acknowledged missing medication tablets and documentation issues |
| V18 | Restorative RN | Discussed treatment for residents' contracted hands |
| V20 | Licensed Practical Nurse / wound care nurse | Observed wound care and mattress use |
| V21 | Certified Nursing Assistant | Assisted with wound dressing change |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident self-administration of medications, advance directives, physical restraints, discharge planning, communication aids, medication monitoring, oxygen safety, IV fluid administration, respiratory care, and food storage in resident refrigerators.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications and obtain physician orders, failure to follow advance directives policy, use of physical restraints without proper orders, inadequate discharge planning, lack of communication aids for non-English speaking residents, failure to monitor high-risk medication lab values, unsecured oxygen cylinders, failure to change soiled midline dressings, improper containment of respiratory equipment, and failure to maintain proper refrigerator temperature logs and food safety.
Deficiencies (10)
Failed to assess residents for self-administering medications and obtain physician orders to have medication stored in resident rooms for 4 residents (R28, R32, R66, R75).
Failed to follow advance directives policy for 2 residents (R40 & R14).
Failed to ensure resident R24 was free from physical restraint (seatbelt) without assessment, consent, or physician order.
Failed to assist with discharge planning for 2 residents (R106 and R14).
Failed to utilize communication tools and provide written information in residents' preferred language for 3 residents (R21, R104, R114).
Failed to monitor lab value medications for cardiac/anti-rhythmic medication digoxin for resident R43.
Failed to secure oxygen cylinders for 5 residents (R2, R28, R32, R58, R110).
Failed to change a loose and soiled midline dressing for resident R17.
Failed to appropriately contain respiratory equipment for 3 residents (R20, R37, R85).
Failed to maintain thermometers, temperature logs, and remove undated or expired food items in resident refrigerators for 5 residents (R28, R32, R85, R90, R110).
Report Facts
Residents reviewed for self-administration of medications: 31
Residents reviewed for advance directives: 31
Residents reviewed for physical restraints: 31
Residents reviewed for discharges: 31
Residents reviewed for communication: 31
Residents reviewed for high risk medications: 31
Residents reviewed for oxygen: 31
Residents reviewed for peripheral lines: 31
Residents reviewed for respiratory care: 31
Residents reviewed for refrigerator safety: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding medication self-administration, advance directives, medication safety, oxygen safety, respiratory care, and refrigerator safety |
| V3 | Social Service Director | Provided statements regarding discharge planning and communication aids |
| V12 | Licensed Practical Nurse | Provided statements regarding advance directives, respiratory equipment care, and refrigerator safety |
| V13 | Registered Nurse | Provided statements regarding medication administration and midline dressing care |
| V17 | Registered Nurse | Provided statements regarding oxygen tank safety |
| V18 | Certified Nursing Assistant | Observed unsecured oxygen tank |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow a resident's plan of care for transfers, which resulted in a resident's foot fracture.
Complaint Details
The complaint investigation found that the facility failed to follow the transfer plan for resident R1, leading to an injury. The failure was substantiated by interviews with staff and the resident's physician, who confirmed the improper transfer caused the fracture.
Findings
The facility failed to follow the transfer plan of care for resident R1, who required extensive assistance with transfers using a mechanical stand assist lift. A male CNA transferred R1 improperly without using the mechanical lift or consulting the resident's transfer status, causing R1's foot to get caught on the wheelchair and resulting in a nondisplaced acute oblique fracture of the right tibia.
Deficiencies (1)
Failure to follow a resident's plan of care for transfers, resulting in a foot fracture.
Report Facts
Residents reviewed for transfers: 3
Date of x-ray: Aug 25, 2023
Date of MDS: May 26, 2023
Date of ADL care plan: Nov 17, 2022
Date of policy: Jul 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Certified Nursing Assistant | Named in improper transfer causing resident injury |
| V2 | Director of Nursing | Provided statements regarding transfer procedures and resident care plan |
| V10 | Restorative Nurse | Provided statements regarding transfer requirements |
| V11 | Resident's Physician | Confirmed improper transfer caused fracture |
| V12 | Registered Nurse | Documented x-ray results and resident condition |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement care planned fall interventions for a resident identified as high risk for falls.
Complaint Details
The investigation was complaint-related, focusing on fall interventions for resident R7. The complaint was substantiated as the facility did not follow the care plan to keep the resident's bed in the lowest position, contributing to a fall.
Findings
The facility failed to implement fall precautions as per the care plan for one resident (R7) who had multiple prior falls and injuries. The resident's bed was not kept in the lowest position as required, contributing to a fall incident on 6/29/2023. The facility policy mandates assessment and implementation of fall interventions, but these were not adequately followed.
Deficiencies (1)
Facility failed to implement care planned fall interventions for resident R7, including keeping the bed in the lowest position.
Report Facts
Residents reviewed for falls: 10
Residents reviewed for falls with care plans: 4
Fall Incident Date: Jun 29, 2023
Brief Interview of Mental Status score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Nursing Assistant | Provided statement regarding bed height at time of fall |
| V2 | Director of Nursing | Confirmed fall precautions and bed height requirements |
| V13 | Medical Director | Provided medical opinion on resident's falls and injuries |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, environment cleanliness, catheter care, social services and discharge planning, infection control, and vaccination policies at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to conceal urinary drainage bags in dignity bags for residents, failure to maintain a clean and homelike environment after room changes, improper catheter care risking infection, inadequate assistance with discharge planning and social services, failure to ensure proper use of personal protective equipment for infection control, and failure to offer pneumococcal vaccines to some residents.
Deficiencies (6)
Urinary drainage bags were not concealed in dignity bags for 2 of 24 residents (R12, R31).
Resident's room was not clean, comfortable, and homelike after a room change for 1 of 24 residents (R62).
Urinary catheter was not maintained properly to prevent infection for 1 of 8 residents (R272).
Facility failed to assist a resident and resident representative with discharge planning for 1 of 23 residents (R94).
Required Personal Protective Equipment (PPE) was not worn during resident care for 1 of 24 residents (R31) on enhanced barrier precautions.
Facility failed to offer both pneumonia vaccines (PCV13 and PPSV23) for 3 of 5 residents (R12, R26, R272).
Report Facts
Residents reviewed for dignity: 24
Residents reviewed for homelike environment: 24
Residents reviewed for catheters: 24
Residents reviewed for social services/discharge planning: 24
Residents reviewed for infection control: 24
Residents reviewed for vaccines: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Certified Nursing Assistant | Named in findings related to urinary drainage bag dignity violation and failure to wear gown during enhanced barrier precautions |
| V6 | Licensed Practical Nurse | Named in findings related to catheter care and infection control |
| V4 | Wound Care Nurse | Named in findings related to infection control PPE use |
| V12 | Social Services | Named in findings related to discharge planning deficiencies |
| V13 | Resident's Power of Attorney | Named in findings related to discharge planning complaint |
| V3 | Infection Control Nurse | Named in findings related to vaccination and infection control |
| V14 | Certified Nursing Assistant | Named in findings related to room cleanliness after room change |
| V2 | Director of Nursing | Named in findings related to room cleanliness expectations |
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