Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grove Of Fox Valley,the during CMS and state inspections, most recent first.
A dependent, severely cognitively impaired resident with multiple comorbidities and a G-tube sustained extensive full- and partial-thickness burns to the left torso, flank, back, and thigh while under facility care. A CNA new to the resident provided care alone despite the resident typically requiring two staff, observed G-tube leakage onto the left abdomen during the night, and did not report it to a nurse. Later, CNAs changing the resident’s brief found wetness and abnormal whitish-red skin discoloration on the left abdomen, which a nurse initially described as a rash before the resident was sent to the ED and then a burn center, where third-degree contact burns were identified. The facility’s investigation attributed the injuries to over-the-counter lotion or heparin and documented no harm, despite external clinicians determining the wounds were full-thickness burns, and no clear source of the burn hazard was identified.
A resident who was severely cognitively impaired, dependent for all ADLs, and fed via G-tube sustained full- and partial-thickness burn injuries to the left torso and flank. The facility’s investigation relied on opinions that heparin injections or an over-the-counter lotion might have caused a chemical burn, even though burn center providers documented that the injury pattern could not be explained by a rash, heparin, or lotion and was more consistent with contact injury such as gastric contents or very hot bath water. The Administrator and DON did not review burn images or consult with burn center clinicians about the likely cause, the final report documented no harm, and a CNA’s report that the G-tube had leaked onto the resident’s left abdomen during an overnight shift was omitted from the written investigation, contrary to facility policy requiring exploration of all possible related circumstances for injuries of unknown origin.
Surveyors found that the facility failed to follow urology recommendations for timely catheter changes, did not obtain or document appropriate catheter-change orders, and did not complete required assessments or care plans for indwelling catheter use for two residents. One resident with severe cognitive impairment and prostatic obstruction had no documented catheter-change schedule in line with urology guidance, no assessment of catheter indication or plan for removal, and experienced foul-smelling urine, catheter pulling with blood in the drainage bag, and subsequent hospitalization for cystitis and prostatitis. Another resident with neuropathic bladder and a stage 4 sacral ulcer was repeatedly observed with cloudy catheter tubing containing sediment, despite an order to change the catheter when nonfunctioning and a DON expectation that catheters be changed when obstructed or with sediment, and the facility could not provide a comprehensive assessment or plan for catheter removal as required by its catheter policy.
Failure to Follow Hand Hygiene, PPE, and Linen Handling Practices: Staff were observed providing resident care without consistent hand hygiene, gown use, or proper handling of soiled linen. CNAs performed perineal care for residents on EBP without gowns, changed gloves without washing hands, carried soiled linen into hallways, and left or tossed soiled briefs and washcloths improperly. An LPN also removed gloves after a blood glucose check and touched the nursing cart without hand hygiene.
A resident using a personal CGM device was monitored without a documented assessment, physician order, facility policy, instruction manual, or staff training, and staff gave conflicting accounts about whether readings came from the resident’s device or the facility device. Another resident’s metoprolol order and blister pack listed hold parameters that the NP documented as likely reversed, with the NP noting the order needed clarification and the DON stating staff were expected to follow practitioner recommendations.
Improper Maintenance of PICC Line Dressing: A resident with a single-lumen PICC receiving IV antibiotics had a transparent dressing over the insertion site that was bubbled, not secured to the skin, and had dried brown substance underneath it. The RN was responsible for the dressing, but the TAR and physician order did not align with the observed condition, and the DON stated the dressing should have been changed when the soiling was noted.
A resident experienced a significant medication error when an RN entered the hospital discharge metformin order incorrectly, resulting in regular metformin being ordered instead of the extended-release form. The resident reported his meds were not being received as ordered and that his BG had been normal at home but remained high in the facility; the MAR showed multiple doses given and BG readings ranged from 228 mg/dl to 458 mg/dl. The DON confirmed the order entry error, and the pharmacist review reflected the intended metformin 500 mg 24-hour BID order.
Three residents who required staff assistance for incontinence care did not receive timely care, resulting in each being found with saturated briefs after a prolonged period without attention. Care plans specified incontinence care every two hours, but staff failed to provide this due to a CNA leaving mid-shift and delays in coverage, as confirmed by observations, staff, and family interviews.
The facility failed to ensure accurate accounting and integrity of controlled medications, with discrepancies in medication counts and broken seals on blister packs. Nurses did not consistently sign shift change records or medication administration forms, leading to unaccounted medications. Facility policies on medication handling were not followed, resulting in deficiencies in medication management.
A resident with multiple health conditions experienced a delay in receiving a referral to a corneal specialist due to the facility's failure to follow a physician's order. Despite a request from the resident's POA and a diagnosis of central corneal opacity, the appointment process was not initiated by the nurse, resulting in no scheduled appointment.
A facility failed to provide a specialized mattress for a resident with a worsening pressure injury, despite recommendations from a wound care practitioner and the facility's policy. The resident, with multiple diagnoses and at high risk for pressure injuries, had a stage 2 pressure injury that progressed to stage 3. The wound care note recommended an alternating air/low air loss mattress, which was not provided, leading to the deficiency.
The facility failed to apply prescribed interventions for two residents with hand contractures, leading to discomfort and pain. Despite care plans indicating the use of rolled gauze to manage contractures, observations revealed that the interventions were not consistently applied, resulting in the residents' hands remaining tightly closed and contracted.
A resident with celiac disease did not receive a gluten-free diet as ordered by their physician. Despite being cognitively intact and having a care plan specifying a gluten-free diet, the resident received meals containing gluten, such as white bread and a dinner roll. The dietary staff was informed, but the issue persisted.
The facility failed to follow its antibiotic stewardship policy, resulting in inappropriate antibiotic use for two residents. One resident was on ciprofloxacin despite urine culture results showing resistance, and the antibiotic was not changed promptly. Similarly, another resident's antibiotic was not changed in a timely manner after culture results indicated resistance. The Infection Preventionist Nurse did not review culture results during the antibiotic timeout, and there was no documentation of provider notification.
Failure to Protect Dependent Resident From Severe Burns of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to protect a fully dependent, severely cognitively impaired resident from sustaining extensive burn injuries to the left torso, flank, back, and thigh. The resident had multiple comorbidities including a prior cerebral infarction with right-sided hemiplegia and hemiparesis, dysphagia, type 2 diabetes, chronic diastolic CHF, and was NPO with a gastrostomy tube for feeding. The resident’s MDS showed she required substantial assistance for oral hygiene, rolling in bed, and upper body dressing, and was dependent on staff for lower body dressing, bathing, toileting, and transfers. She was fed entirely via gastrostomy tube and was known to be strong and resistive during care, requiring two staff for safe care and repositioning. On one overnight shift, a CNA who was caring for the resident for the first time provided care alone and was unaware that the resident typically required two caregivers. During that shift, the CNA observed the resident’s feeding tube leaking at approximately 2:30 AM and 4:00 AM, with liquid dripping onto the left side of the resident’s abdomen. The CNA only wiped the liquid from the top of the abdomen and did not report the leaking tube to a nurse, believing the leakage was normal, despite there being no physician orders for overnight feedings or flushes. Later, another CNA on a subsequent shift, who assisted with incontinence care, found the left brief tab wet and, upon opening the brief, observed whitish and red discoloration on the left side of the resident’s abdomen that she had never seen before. The nurse who was called to assess the area described it as a rash and notified the nurse practitioner, who received an image and ordered transfer to the emergency room. The resident’s grandson reported that he had brought an over-the-counter lotion for dry skin and left it at the bedside days earlier, but he did not apply it. When he visited again, he found the resident still in bed and not up in her wheelchair as usual, and staff told him the resident had been feisty and had not allowed them to get her up. After he left, he received a voicemail from a nurse stating the resident had developed a rash on the left side of her abdomen that was not serious, followed later by a call that the resident was being sent to the emergency room due to the rash. The emergency room physician later informed him that the resident had third-degree burns on the left side of her abdomen. At the regional burn center, an advanced practice nurse identified two separate full-thickness burn wounds on the left flank with surrounding partial-thickness burns in a linear pattern from the left upper back to the left upper thigh, and stated that the facility’s explanations of lotion or heparin did not account for the pattern or extent of the injuries and that the mechanism of injury would be contact. The facility’s own documentation showed the resident received bed baths rather than showers, with the last bed bath occurring several days before the burns were discovered, and the CNAs who provided that bath stated the water temperature was comfortable. The administrator and DON later reviewed images of the burns from the emergency room and burn center and stated they had not previously viewed these images. They reported that, after looking in the resident’s room, they could not identify a source of injury and concluded in their internal investigation report that the burns were caused by the over-the-counter lotion or heparin, and their report documented that no harm was sustained, despite the burn center’s identification of third-degree full-thickness burns. The facility’s hazard policy stated that hazardous items and situations were to be removed or corrected to prevent accidents, but the events described show that the resident, who was fully dependent on staff and unable to protect herself, was not adequately protected from an accident hazard that resulted in significant burn injuries of unknown origin while in the facility’s care.
Failure to Thoroughly Investigate Burn Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a severely cognitively impaired resident who was dependent on staff for all ADLs and received nutrition via gastrostomy tube. The resident was hospitalized for redness and an open area on the abdomen and redness to the left flank, later identified at a regional burn center as two separate full-thickness burns on the left torso/flank with surrounding partial-thickness burns in a linear pattern from the left upper back to the left upper thigh. The Administrator and DON stated they had not viewed images of the burn injury nor discussed with burn center providers the extent or most likely cause of the injury. The facility’s final report documented physician and NP opinions that heparin injections or an over-the-counter lotion containing alpha-hydroxy acid might have caused a chemical burn, but staff interviews did not identify anyone who had applied the lotion, and most staff were unaware it was in the room. The final report section describing harm stated “none,” despite the burn center’s documentation of full-thickness burn injuries. The burn center’s case management note documented that, after receiving information from the facility’s liaison that the likely cause was a rash or heparin use, the burn service team concluded there was no circumstance in which the admitting injury could be confused with a rash and that long-term heparin injections would not cause a full-thickness burn. The APN-BC from the burn center stated the facility’s explanations involving lotion or heparin did not explain the pattern or extent of the burns and indicated the mechanism of injury would be contact, more likely from gastric contents or very hot water during bathing, given the resident’s NPO status and gastrostomy tube. A CNA reported that during an overnight shift she cared for the resident alone, was unaware two-person care was normally required, had difficulty providing incontinence care, and observed the gastrostomy tube leaking liquid onto the left side of the resident’s abdomen at two different times, but did not report it to the nurse because she thought it was normal. Although the CNA stated she reported the leaking tube during the facility’s investigation, the final investigation report did not include this information, and the facility’s policy requiring exploration of all possible risk factors and related circumstances for injuries of unknown origin was not followed.
Failure to Follow Urology Recommendations and Assess Indwelling Catheter Use
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate catheter care, follow urology recommendations for catheter changes, prevent urinary tract infections, and complete comprehensive assessments for catheter use for residents with indwelling urinary catheters. One resident with severe cognitive impairment and multiple diagnoses, including benign prostatic hypertrophy and hemiplegia, had an indwelling urinary catheter for obstruction due to prostatic enlargement. A urology clinic note recommended catheter changes every 3–4 weeks at the clinic and referred the resident to a closer urologist, but the facility could not provide documentation that these recommended catheter changes occurred between a catheter change in late January and a scheduled appointment in late April. The resident’s EMR contained no assessment for the indication of catheter use, no ongoing assessment of the need for continued use, and no plan for removal, and there were no physician orders addressing catheter change. On one evening shift, an LPN reported that the resident’s sister complained of foul-smelling urine; the LPN changed the drainage bag and flushed the catheter with 50 cc normal saline without a physician order and without documenting this in the progress notes. The following day, an RN observed blood in the urinary drainage bag, assessed the resident, and found the catheter securement device too taut and pulling on the catheter. The RN repositioned the securement device, flushed the catheter, and obtained a urine specimen, after which the resident reported relief and the blood was no longer visible in the catheter. Subsequently, at the request of the resident’s sister, the resident was transferred to the hospital for a catheter change, and progress notes documented admission to the hospital for cystitis and prostatitis and readmission on antibiotics for a urinary tract infection. The DON stated the last known catheter change was in the emergency room in late January and was unsure if the catheter had been changed during a cystoscopy in February, and the facility could not show that urology recommendations for catheter changes every 3–4 weeks had been followed. A second resident with multiple diagnoses, including uninhibited neuropathic bladder, adult failure to thrive, and a stage 4 sacral pressure ulcer, was dependent on staff for all ADLs and had an indwelling urinary catheter. On two consecutive observations, this resident’s catheter tubing appeared cloudy and contained sediment. The LPN wound care nurse stated that the catheter should be changed when it stops draining or when there is sediment in the tubing and acknowledged that the catheter appeared to need changing at that time. The physician’s order for this resident directed staff to change the catheter and drainage bag when nonfunctioning, but the facility was unable to provide a completed comprehensive assessment for the indication of catheter use or a plan for catheter removal upon request. The facility’s own indwelling catheter policy required that an indwelling catheter assessment be completed by a nurse, that a physician’s order be obtained, that a care plan for catheter use be made, and that catheters and urine bags may be changed PRN, but these elements were not demonstrated in the records reviewed for these residents.
Failure to Follow Hand Hygiene, PPE, and Linen Handling Practices
Penalty
Summary
The facility failed to implement infection prevention and control practices during resident care, including hand hygiene, use of PPE, and handling of soiled linen. During observation of incontinence care for a resident with peripheral vascular disease, hypertensive heart disease, an acquired right below-knee amputation, anemia, and urinary retention, a CNA wore PPE initially but did not perform hand hygiene when changing gloves between dirty and clean tasks, did not complete hand hygiene after removing gloves or PPE, and carried soiled linen to the hallway without placing it in a plastic bag for transport. The resident’s care plan also identified Enhanced Barrier Precautions related to a left groin abscess and directed gown and glove use during high-contact care. A second resident with hypertension, diabetes mellitus, chronic kidney disease, paraplegia, peripheral vascular disease, impaired cognition, and bowel and bladder incontinence required total assistance with ADLs and was on Enhanced Barrier Precautions for an unstageable sacral pressure injury. A CNA provided perineal care without wearing a gown, did not perform hand hygiene before or after care, and then carried a bag of soiled linen into the hallway while wearing the same soiled gloves and discarded the items in the soiled utility room before removing gloves and again failing to perform hand hygiene. Additional observations showed similar failures with other residents. A CNA provided perineal care to a resident with multiple chronic lower-extremity ulcers and atherosclerosis with ulceration while wearing gloves only and without a gown, and did not perform hand hygiene before or after care. Another CNA left soiled washcloths draped over the footboard and mattress pump, with the washcloths in contact with the resident’s feet and bed linens, and tossed a soiled brief across the bed toward the trash receptacle, where it landed on the floor, without hand hygiene. An LPN performing a blood glucose check on a resident on Enhanced Barrier Precautions removed gloves and then touched the nursing cart without washing hands. The DON stated that staff should don PPE before entering rooms with Enhanced Barrier Precautions signs, change gloves and perform hand hygiene when moving from dirty to clean tasks, bag soiled linen for transport, and doff inside the room with hand hygiene before exiting.
Inaccurate glucose monitoring process and incorrect metoprolol hold parameters
Penalty
Summary
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 another resident’s blood pressure medication. For the resident using a personal continuous glucose monitoring system, the resident stated he monitored his own glucose levels with a sensor attached to his skin that sent readings to his personal cellular device, and he reported the results to nursing staff. The DON stated the resident had not been assessed for use of his personal glucose monitoring system and that there was no physician order for self-glucose monitoring. Nursing staff gave conflicting accounts, with one RN stating staff obtained readings from the resident’s device and documented them in the EMR, while an LPN stated she had no knowledge of how quality assurance monitoring was done, did not know the device name, and had no instructions or policy for the device. The DON also stated she was unaware staff were documenting readings from the resident’s personal device and that there was no facility policy, instruction manual, or staff training for the device. For the second resident, the physician order for Metoprolol Succinate ER 50 mg stated to give one tablet daily and hold if systolic blood pressure was greater than 110 or heart rate was greater than 60. The medication packaging matched those same hold directions, but the NP’s progress note documented that the hold parameters appeared incorrect and that they likely should be hold if systolic blood pressure was less than 110 or heart rate was less than 60. The NP stated she notified nursing staff and expected the order to be clarified, and she explained that the medication could be held when it should be administered or administered when it should be held. The DON stated nursing staff were expected to carry out practitioner recommendations, including clarification of incorrect medication orders.
Improper Maintenance of PICC Line Dressing
Penalty
Summary
The facility failed to properly maintain a venous access device for a resident with a single-lumen PICC in the left upper arm who was receiving IV antibiotics twice a day. On 03/24/2026 at 11:03 AM, the PICC line was observed covered by a transparent film dressing that had a dried brown substance underneath it at the insertion site, and the dressing was bubbled and not in contact with the resident’s skin at the insertion site. The dressing was dated 3/16/26, and the resident did not know the day or date when the PICC dressing had last been changed. On 03/25/2026 at 4:52 PM, the DON stated PICC line dressings are changed every seven days and as needed, and that the RN assigned to the resident is responsible for maintaining the dressing. The DON stated the dressing should have been changed when the dried brown substance was noted and that if the dressing was placed on 3/16/26 it should have been changed on 3/23/26. The resident’s TAR documented the most recent PICC line dressing change as completed on 3/22/26, while the current physician order directed PICC line dressing changes every Sunday night shift. The facility policy stated central line dressings are to be done every 7 days and the outside of the dressing is to be labeled with the dressing change date and time.
Significant Metformin Order Entry Error
Penalty
Summary
A resident was found to have a significant medication error involving metformin after admission to the facility. The resident stated that prescriptions he had been taking previously were not being received as ordered and that the facility had been provided a list of his medications. He also stated that his blood glucose had been normal at home but had been too high since being in the facility. The resident’s hospital discharge summary ordered metformin 500 mg 24-hour tablet, one tablet in the morning and one tablet in the evening, and the pharmacist’s medication regimen review also reflected metformin 500 mg 24-hour twice daily, with a note to review, verify, and update PCC as appropriate. Facility staff identified that the metformin order had been entered incorrectly. The DON stated the RN entered the order incorrectly, and the RN stated he entered the hospital discharge medication list and called it to the physician, but entered regular metformin instead of the extended-release metformin. The MAR showed the resident received nineteen doses of metformin 500 mg over ten days, while blood glucose readings from 03/15/2026 to 03/25/2026 ranged from 228 mg/dl to 458 mg/dl. The facility policy on verification of physician orders stated its purpose was to reduce errors associated with misinterpreted verbal or telephone communications of medication orders or test results, and that a summary order to resume previous orders for medications shall not be accepted.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for three residents who were dependent on staff for activities of daily living (ADLs), specifically incontinence care. All three residents had care plans directing staff to provide incontinence care every two hours and as needed. On the morning in question, these residents were not provided incontinence care from the end of the night shift (around 5:00 A.M.) until late in the morning, resulting in each being found with saturated incontinence briefs. Certified Nursing Assistants (CNAs) assigned to these residents did not provide the required care during their shift, with one CNA leaving the facility for personal reasons without attending to these residents. Another CNA subsequently provided care, but only after a significant delay. Interviews with the residents and their representatives confirmed that delays in incontinence care were a recurring issue, with reports of residents often being found soaked with urine and staff attributing the delays to other shifts. The electronic medical record and care plans confirmed the residents' dependence on staff for incontinence care and the required frequency of care, which was not met on the day of observation. The deficiency was directly observed and corroborated by staff and family interviews.
Deficiencies in Controlled Medication Management
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications, as well as maintaining the integrity of blister packs containing these medications. During an observation on January 7, 2025, it was found that the shift change accountability record for controlled substances was not signed by both the incoming and outgoing nurses, leading to discrepancies in medication counts. For instance, a blister pack of Pregabalin for a resident was missing one tablet, which was not signed out on the controlled drug administration record form. Additionally, a blister pack of Hydrocodone-APAP had broken seals on three tablets, which should have been wasted and witnessed by another nurse according to facility policy. Further observations revealed similar issues with other residents' medications. A blister pack of Tramadol for another resident was missing a tablet, which was not signed out after administration. Another resident's blister pack of Alprazolam had a broken seal on one tablet, and a blister pack of Oxycodone IR was missing a tablet without explanation. Additionally, a blister pack of Lorazepam showed an incorrect count, as the medication was reportedly administered but the count remained unchanged. These discrepancies indicate a failure to properly document and account for controlled medications. The facility's policies on controlled medication counts and medication labels were not adhered to, as evidenced by the lack of proper documentation and handling of medications. The Director of Nursing acknowledged that the nurses should sign the controlled drug administration record immediately after removing medication from the blister pack to prevent discrepancies. The facility's policy also requires that any controlled medication with a broken seal should be discarded and witnessed by two nurses, which was not consistently followed. These failures in procedure led to the observed deficiencies in medication management.
Failure to Schedule Corneal Specialist Appointment
Penalty
Summary
The facility failed to follow a physician's order to obtain a referral for a corneal specialist for a resident with multiple diagnoses, including Parkinson's disease, chronic kidney disease, and type 2 diabetes. The resident, who was admitted to the facility, reported difficulty seeing and had a referral from an eye doctor, but no appointment had been made. The social services staff received an email from the resident's POA requesting an appointment at a local eye clinic, but due to being out of the office, the process was delayed. Upon returning, the social services staff notified the resident's nurse to schedule the appointment, but the nurse had not started the process. An eye doctor's note indicated a diagnosis of central corneal opacity and a care plan to consult with a corneal specialist, but as of the survey date, no appointment had been scheduled. The Director of Nursing acknowledged that there should not have been a delay in scheduling the appointment.
Failure to Provide Specialized Mattress for Pressure Injury
Penalty
Summary
The facility failed to provide a specialized mattress for a resident with a worsening pressure injury, despite recommendations from a wound care practitioner and the facility's own policy. The resident, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a history of cerebral infarction, was identified as being at high risk for developing pressure injuries. The resident's medical record indicated a stage 2 pressure injury on the bilateral glute, which later progressed to stage 3. The wound care progress note recommended an alternating air/low air loss mattress for pressure redistribution, which was not provided. During an observation of a wound dressing change, the LPN noted that the resident was using a two-tone pressure redistribution mattress and acknowledged that the resident, who had become weaker, could benefit from a low air loss mattress. The facility's policy stated that residents with stage III and/or IV pressure injuries should be placed on specialized air mattresses, such as a low air loss mattress. However, this was not implemented for the resident, leading to the deficiency noted in the report.
Failure to Implement Prescribed Interventions for Contractures
Penalty
Summary
The facility failed to ensure that interventions were applied to provide comfort and prevent further worsening of contractures in two residents. Resident R17, a cognitively intact female with multiple diagnoses including congestive heart failure and dementia, was observed multiple times with her left hand tightly closed and contracted, without any rolled gauze as ordered by her physician. Despite the care plan indicating that rolled gauze should be applied to her left hand after morning ADL care, it was not consistently done, leading to pain when attempts were made to open her hand. Similarly, Resident R41, a cognitively impaired female with diagnoses including chronic systolic heart failure and quadriplegia, was observed with her left hand contracted and without the rolled gauze that was supposed to be applied. The care plan for R41 indicated that rolled gauze should be applied to her left hand after morning ADL care and removed during meals and bedtime, but this was not adhered to. Both residents experienced pain when attempts were made to open their contracted hands, indicating a failure in the facility's implementation of prescribed interventions to manage their conditions.
Failure to Provide Gluten-Free Diet to Resident with Celiac Disease
Penalty
Summary
The facility failed to provide a diet that accommodated a resident's dietary preferences and medical needs, specifically for a resident diagnosed with celiac disease. The resident, who was cognitively intact, had a physician-ordered diet that included a No Added Salt (NAS) diet, regular texture, thin liquids consistency, and gluten-free requirements. Despite these orders, the resident received meals that included gluten-containing items, such as white bread and a dinner roll, which were not suitable for their gluten-free diet. On two separate occasions, the resident received meals that did not comply with their dietary restrictions. On the first occasion, the resident received a slice of white bread, and on the second occasion, a dinner roll was included in their meal. Both items were not gluten-free, as confirmed by the dietary manager. The resident expressed concerns about receiving gluten-containing foods, indicating it was not the first time this had occurred. The dietary staff, including the guest services representative and dietary manager, were notified of the issue, but the resident continued to receive inappropriate food items.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy, resulting in inappropriate antibiotic use for two residents. Resident R15 was started on ciprofloxacin for a urinary tract infection, but the urine culture results showed resistance to this antibiotic. Despite the results being available on October 26, 2024, the antibiotic was not changed until October 28, 2024. The Infection Preventionist Nurse did not review the urine culture results during the antibiotic timeout, and there was no documentation that a provider was notified of the culture results. The Director of Nursing acknowledged that the timeout process should include reviewing culture results and ensuring the resident is on the correct antibiotic. Similarly, Resident R32 was also started on ciprofloxacin for a urinary tract infection, with culture results indicating resistance. The results were available on November 10, 2024, but the antibiotic was not changed until November 12, 2024. Again, the Infection Preventionist Nurse did not review the culture results during the timeout, and there was no documentation of provider notification. The facility's policy requires a reassessment of antibiotic use three days after initiation, but this was not documented for either resident. The lack of adherence to the policy led to delays in providing the appropriate antibiotic treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Aurora | 2.2 mi | ★★★★★ | 1 | 0 |
| Asbury Gardens Nsg & Rehab | 2.3 mi | ★★★★★ | 5 | 0 |
| North Aurora Living & Rehab Ctr | 2.4 mi | ★★★★★ | 1 | 0 |
| Jennings Terrace | 3.2 mi | ★★★★★ | 0 | 0 |
| La Bella Of Aurora | 3.5 mi | ★★★★★ | 3 | 0 |
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