Health inspection·August 30, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/27/24 at 1:07 PM. surveyor and V8 (Maintenance Director) toured throughout the facility taking random room temperatures. R69's room temp was 80.6 degrees (relative humidity was not relayed at that time and was not documented). On 8/28/24 at 11:30 AM, V23 (Concerned party) said administrator in training is aware of air conditioning issues and said R1's side of the facility has air conditioning issues. Concerned party said this has been an issue since May. Concerned party said air conditioning issues should have been addressed by now. On 8/28/24 at 9:18 AM, R69 said the air conditioner in his room doesn't work thus he was not feeling well. R69 said he was nauseous and had loss of balance. On 8/29/24 at 9:22 AM, V1 (Administrator) said the room temperature should not be higher than 80 degrees. V1 said V8 is responsible for documenting temperatures and relative humidity on extreme heat days. V1 said he did not see relative humidity documented on the temperature log sheet for 8-26-24 and 8-27-24 (Extreme Heat Days). On 8/29/24 at 10:36 AM, V8 (Director of Maintenance) said he did check the relative humidity on Monday and Tuesday (Extreme Heat Days) however V8 did not document relative humidity in the temperature. V8 said the humidity affects extreme heat and will make the environment more stuffy or uncomfortable for the resident. V8 said room temperatures should be below 80 degrees. Extreme High Temperature Guideline (revised 4/3/24) documents: Should the temperature index for relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. Temperature Log dated August 2024 does not document relative humidity levels for 8/26/24 and 8/27/24 (extreme heat days) as verified by Administrator and Director of Maintenance. Based on observation, interview, and record review the facility failed to implement their appropriate extreme high temperature policy and procedures in the facility. This deficiency affects two (R103 and R69) of three residents in the sample of 23 reviewed for Safe and comfortable resident environment. Findings include: Page 1 of 11 145211 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. On 8/27/24 at 11:54AM, Rounds were made to the 2nd floor unit. Surveyor felt warm air on the unit and noted two electric fans by the nursing station; there was no electric fan by the unit hallway. On 8/27/24 at 12:18PM, Observed R103 sitting in a wheelchair, wearing a gown and a brief. R103 complained that he cannot sleep because his room is hot. He said he feels exhausted. He was observed trying to remove his gown and appears restless. R103 keeps saying the room is hot. The window curtain was observed open with sunlight going through the window and into his room. The air conditioner was located by the window with warm air coming out. Showed observation to both V12 (Licensed Practical Nurse/LPN) and V2 (Director of Nursing/DON), both said that they are not aware of R103's room situation and V8 (Maintenance Director) was called. On 8/27/24 at 12:27PM, V8 (Maintenance Director) informed of R103's room situation. V8 did measure the room temperature using relative humidity temperature meter and his room reading was 84 degrees Fahrenheit (F). V8 said that temperature should be at least 80 degrees Fahrenheit. On 8/27/24 at 12:32PM, Rounds made with V8 (Maintenance Director) on the 2nd floor unit. V8 took the temperature of the hallway and obtained 86.4 degrees (F). V8 took the temperature of the dining room and obtained 86.8 degrees (F). The dining room has 2 electric fans. There were 6 residents in the dining room, sleepy and unable to be interviewed. Observed water station by the nursing station but no staff handling or offering the water to the residents. On 8/29/24 at 10:26AM, Reviewed R103's medical records with V2 (DON). No documentations of R103's being monitored for his intake and output of fluids. No documentation of encouragement of fluid intake. No documentation of R103's signs of discomfort, symptoms of heat stroke and heat exhaustion. V2 said that they don't have any documentation of monitoring indicated in their extreme high temperature guideline. On 8/29/24 at 10:42AM, V8 (Maintenance Director) said that they installed a new air conditioner for R103. V8 said that he usually monitors the temperature daily and in extreme heat every 2 hours, but he said that he did not document it. V8 said that acceptable resident room /environment temperature is below 80 degrees (F). He does not measure and document humidity, only temperatures. Reviewed facility's policy on extreme high temperature with V8. He said that he did not have documentation of monitoring of facility 's room /areas for temperature and humidity every 2 hours from 8am to 10pm and every 4 hours from 10pm to 8am. He does not have documentation of monitoring of ventilation system and air conditioning system. On 8/29/24 at 2:26PM, Informed V1 (Administrator) of above concerns. R103 is admitted on [DATE] with diagnosis listed in part but not limited to Hypertension, Diabetes Mellitus type 2, Vascular dementia, Chronic pulmonary disease, anxiety disorder. Facility's policy on Extreme high temperature guideline revised 4/3/2024 indicates: Purpose: To provide guidance to the facility in times of unseasonable hot weather and or cooling system malfunction. Should the temperature index relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. 145211 Page 2 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0584 Level of Harm - Minimal harm or potential for actual harm Should a specific area of the facility rise above 80 degrees, it may be necessary to relocate residents to a cooler section of the facility. If the high temperature procedures do not sufficiently maintain resident safety, the facility shall consult with the Department of Public Health regarding advisability of resident evacuation. Residents Affected - Few Department specific procedures: Nursing: *Monitor residents for intake and output of fluids. Encourage fluids. *Monitor residents closely for signs of discomfort and adverse physical symptoms. *Monitor all residents frequently for symptoms of heat stroke and heat exhaustion. *Offer cool fluids, ice cream, popsicles regularly. Dietary: *Prepare hydration stations for nursing stations and resident areas Maintenance: * Monitor air temperatures at least every 2 hours between 8:00am and 10:00pm in the resident areas and every 4 hours between 10:00pm and 8:00am. Temperatures should be taken at the warmest point identified through baseline monitoring on each floor or wing. Include day rooms, dining rooms, activity rooms and resident rooms. * Monitor all ventilation systems and ensure they are in working condition *Monitor all air conditioning systems. Clear areas around units of vegetation and debris allow better air flow. Clean air conditioning filters. Check all blower motors. Assure water lines to the building are working appropriately. 145211 Page 3 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement the written policy and procedure that prohibit and prevent abuse. This deficiency affects all four (R46, R66, R106 and R107) residents in the sample of 23 reviewed for Abuse prevention Program. Residents Affected - Some Findings include: On 8/28/24 at 12:35PM, V9 (Social Service Director/SSD) that they have four identified offender residents in the facility. Review medical records of R46, R66, R106 and R107. Noted that they don't have care plan developed as an identified offender in their charts. V9 said that she does not develop care plan for identified offender residents. She added that she is not aware that she must develop for them. Reviewed facility's identified offender policy with V9 indicates that care plan should incorporate resident who is identified offender including security measures. On 8/28/24 at 2:26PM, Informed V1 (Administrator) of above concern. V1 said that he will talk to V9 (SSD). Review R106's medical records. Unable to locate abuse/neglect screening upon admission. Requested copy of record to V2 (Director of Nursing/DON). On 8/29/24 at 9:40AM, V2 presented copy of R106's admission abuse/neglect screening assessment done on 8/28/24. Informed V2 said that social services do the abuse assessment for all residents upon admission. On 8/29/24 at 1:26PM, V9 (SSD) said that social services do the abuse assessment of resident upon admission. Informed V9 that R106 is admitted on [DATE] and abuse admission assessment was documented and completed in R106's chart on 8/28/24. V9 said that there are only 2 social services in the facility. V9 added that she documented in paper before she documented in resident's chart. Review R46, R66 and R107's admission abuse assessment. No abuse assessment done upon admission. V9 said that she has not completed the assessment in resident's chart. R106 is admitted on [DATE]. R46 is admitted on [DATE]. R66 is admitted on [DATE]. R107 is admitted on [DATE]. All residents are identified offenders. On 8/29/24 at 2:18PM, Informed V1 (Administrator) of concern identified that abuse assessment /screening as part of the abuse prevention program of the facility is not implemented. Facility's policy on Abuse prevention policy indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. 145211 Page 4 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0607 IV. Establishing a resident sensitive environment. Level of Harm - Minimal harm or potential for actual harm Resident assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Residents Affected - Some Facility's policy on Identified offender indicates: Policy statement: It is the policy of this facility to establish a resident sensitive and resident secure environment. In accordance with the provisions of the Nursing Home Act, this facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Definition: Identified Offender: any person who has been convicted of, found guilty of, adjudicated delinquent for, found not guilty by reason of insanity for, or found unfit to stand trial for, any of the statute citation number listed in the identified offender conviction list or any of the statute citation numbers listed in the sex offenses list of the (state surveying agency) identified offender program attached to this procedure. Care Planning: Upon admission of an identified offender or the decision to retain an identified offender in the facility, in consultation with the medical director and law enforcement shall specifically address the resident's needs in an individualized plan of care. *The facility shall incorporate the identified offender report and recommendations report into the identified offender's plan of care including the security measures listed. * The facility shall evaluate the care plans at least quarterly for identified offenders to make sure the areas related to the identified offence are still appropriate and effective. This review shall be documented, and the care modified as needed. * The facility shall remain responsible for continuously evaluation the identified offender and for making any changes in the care plan that are necessary to ensure the safety of residents. 145211 Page 5 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 follow the facility's policy for using Low Air loss mattress regarding bed linens for a resident with skin impairment. This deficiency affects one (R7) of three residents in the sample of 23 reviewed for Prevention of Pressure wounds protocol. Residents Affected - Few Findings include: On 8/27/24 at 11:58AM, Observed R7 lying in bed with low air loss (LAL) mattress. V12 (Licensed Practical Nurse/LPN) said that R7 has pressure ulcer and on wound care management. Checked bedding with V12 and V2 (Director of Nursing/DON). Observed multi-layers of linen. R7 has folded linen in quarters used as draw sheet and cloth pad over the LAL mattress. R7 wears disposable adult brief. V2 (DON) said that resident on LAL mattress should only be on a flat sheet over the LAL mattress. V2 instructed V12 (LPN) to inform the CNA (Certified Nursing Assistant) to remove the folded linens and cloth pad underneath R7. On 8/28/24 at 11:38AM, V11 (Wound Care Nurse) said that resident on LAL mattress should only have 2 layers- adult brief and flat sheet, adult brief and cloth pad, or no brief but with flat sheet and cloth pad. V11 said that R7 should only have 2 layers- brief and flat sheet or cloth pad not both. R7 is re-admitted on [DATE] with diagnosis listed in part but not limited to Peripheral arterial disease, Bed confinement status, Severe morbid obesity due to excess calories, Venous Insufficiency. Active physician order sheet indicates: Pressure reduction mattress. Comprehensive care plan indicates: R7 has an actual alteration in skin integrity due history of pressure ulcers, decreased mobility. Interventions: Low air loss mattress for pressure reduction while in bed. Facility's policy on Prevention of Wounds effective date: January 2017 indicates: Purpose: to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Interventions and Preventive measures: General Preventive measures: 2. For a person in bed: c. If a special mattress is needed, use one that contains foam, air as indicated. Residents with risk factors-bed fast: 2. Use a special mattress that meets clinical condition. Facility's policy on Low air loss mattress 7/2012 indicates: Purpose: to provide features of a mattress support system that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin. Low air loss mattresses will be utilized for residents with Stage III, IV and unstageable pressure ulcers of the trunk as well as residents 145211 Page 6 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0686 with multiple stage II pressure ulcers. Level of Harm - Minimal harm or potential for actual harm Procedure: 5. A single non-fitted sheet may be used on the mattress for assistance with repositioning. Residents Affected - Few 145211 Page 7 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement its fall preventive interventions for a resident who is at high risk for falls. The facility failed to implement its policy on investigating and reporting resident's incident. The facility failed to assess accurately a resident who smokes in the facility. This deficiency affects all four (R6, R7, R103 and R106) residents in the sample of 23 reviewed for Resident safety. Findings include: 1. On 8/27/24 at 11:58AM, Observed R7 lying in bed, on semi-Fowlers position. She has oxygen via nasal cannula. Her bed is in high position. She has folded floor mat on side of the wall - one closer to the window side and the other one closer to the bathroom side. V12 (Licensed Practical Nurse/LPN) said, she is not sure if R7 is on fall precaution, but she is sure of R6 (the roommate). On 8/27/24 at 12:05PM, Observed R6 lying in bed with floor mat only on the right side of the bed (by the window side). The bed is on high position. V12 (LPN) took the floor mat on the side of the wall of R7 and placed it on R6's left side of the bed. Noted star sticker placed next to both R7 and R6. V12 said that both residents are on fall precautions. V12 said that star sticker that are placed next to the resident name by the door indicates that they are high risk for falls. V2 (Director of Nursing/DON) came to the room. Showed observation made. V2 said that R6 should have floor mat on both side of the bed and bed should be on the lowest position. V2 took the bed control and placed the bed to the lowest position. On 8/27/24 at 12:30PM, Review R6 and R7 medical records with V12 (LPN). Both residents are at high risk for falls due to history of falls. Both care plan interventions indicated: Bilateral floor mat and bed in the lowest position when resident is in bed. On 8/29/24 at 11:45AM, Review R6 and R7 medical records with V2 (DON). R6 is re-admitted on [DATE] with diagnosis listed in part but not limited to Vascular dementia, Muscle wasting and atrophy, Muscle weakness, Anxiety disorder, Gastrostomy. Most recent fall assessment done on 5/8/24 indicated that she is at high risk for fall. Comprehensive care plan indicated that she is at risk for falling related to cognitive and mobility impairment, medication profile and multiple medical comorbidities contributing to risk of fall. Interventions: Bilateral fall mats at bedside. Keep bed in lowest position with brakes locked. Fall incidents: Unwitnessed fall on 4/2/24. R6 was found on lying on the floor. R6 was trying to get out from bed. Witnessed fall on 5/8/24. R6 slide from the bed. R7 is re-admitted on [DATE] with admitting diagnosis listed in part but not limited to abnormalities of gait and mobility, Weakness, Delusional disorders, anxiety disorder. No Fall admission assessment was done. Unwitnessed fall incident dated 8/19/24, found lying on the floor. R7 said that she slid from bed. No fall assessment was done after the fall incident. V2 (DON) said that she is at high risk for falls. Comprehensive care plan indicated that she is at risk for fall related to bilateral weakness limitation to bilateral lower extremities, medications, and other disease conditions that increases risk for falls. Interventions: May have bilateral floor mats. Keep bed in the lowest position with brakes locked. Care plan does not indicate that R7 does not want her bed in the lowest 145211 Page 8 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0689 position. Level of Harm - Minimal harm or potential for actual harm 2. On 8/27/24 at 12:18PM, Observed R103 sitting in a wheelchair, wearing gown and brief. R103 complained that he cannot sleep because of his room is hot. He said he feels exhausted. Observed left hand thumb is reddened and swollen. R103 said that he caught his hand at the bathroom door 2 weeks ago or last week, he cannot remember. Residents Affected - Some Review R103's medical records. No documentation of incident and investigation of left hand reddened and swollen thumb. On 8/28/24 at 11:22AM, Observed R103 up in wheelchair sitting in the hallway across the nursing station. R103 still with reddened and swollen left thumb. On 8/28/24 at 11:28AM, Interviewed V16 (Registered Nurse/RN), V17 (Certified Nurse Assistant/CNA) and V18 (CNA) who were at the nursing station and were not aware of R103's incident of left thumb. All said that they are not aware that R103 has reddened and swollen left thumb. V3 (Assistant Director of Nursing/ADON) is also not aware of the incident. V16 said, she is the nurse assigned to R103. V16 said that X-ray was done today for R103's right elbow, left thumb and bilateral knees. Surveyor asked for incident report for R103's left thumb. V3 (ADON) and V16 (RN) were not aware if an incident report was made. Both searched R103's e-chart and were unable to locate one. Both said that an incident report of unknown injury form is usually documented under events, but nothing was found in R103's chart except the progress notes. Called V2 (DON). V2 said that she is not aware of R103's reddened and swollen left thumb. V12 (LPN) did not report to her nor made an incident report. V2 said that any incident, regardless of how minor, including injuries of unknown source must be reported to the supervisor and report form must be completed. V2 said that she will initiate the incident report and investigation. R103 is admitted on [DATE] with diagnosis listed in part but not limited to Vascular dementia, Anxiety disorder, Psychosis, Communication deficit, Diabetes Mellitus type 2. 3. On 8/28/24 at 11:20AM, Observed with V3 (ADON) that R106 lying in bed in his room. R106 said that he smokes three times a day and as needed. He keeps his cigarette and lighter with him. Observed cigarettes on top of his bedside drawer. V3 (ADON) said that social service does the smoking assessment to resident who desire to smoke in the facility. R106 is admitted on [DATE] with diagnosis listed in part but not limited to Psychosis. He is an identified offender. Smoking assessment done on 8/17/24 indicated that he does not smoke. On 8/28/24 at 1:30PM, Informed V2 (DON) of above observation and that smoking assessment was not done accurate to R106 who smokes and keeps his cigarette and lighter at bedside. V2 said that smoking assessment should be completed to resident who desires to smoke for safety. Facility's policy on Fall guidelines revised on 8/2024 indicates: Fall prevention is achieved through an IDT approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches. 145211 Page 9 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0689 Fall Management (Determination of risk): Level of Harm - Minimal harm or potential for actual harm *Develop and implement interventions. Facility's policy on Accidents/Incidents/Events- Investigating and Reporting revised August 2008 indicates: Residents Affected - Some Policy statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises must be investigated and reported to the administrator. Policy and interpretation and implementation: 1. Reporting of accidents/incidents: a. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. b. A report form must be completed for all accidents or incidents. d. The Nurse Supervisor/Charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided. 4. Investigative action: a. The nurse supervisor/charge nurse and or the department director or supervisor must conduct an immediate investigation of the accident or incident. b. The following data, as it may apply must be included on the report of incident/accident form: (1) The date and time the accident or incident took place; (2) The nature of the injury/illness (e.g., bruise, fall, nausea, etc.) (3) The circumstances surrounding the accident or incident (4) Where the accident or incident took place (6) The injured person's account of the accident or incident (7) The time the injured person's attending physician was notified (8) The date/time the injured person's family was notified and by whom (9) The condition of the injured person's, to include his or her vital signs (10) Any corrective action taken (12) Follow up information 145211 Page 10 of 11 145211 08/30/2024 Thryve of Burbank 5400 West 87th Street Burbank, IL 60459

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some c. A completed report of incident/accident form must be submitted to the Director of Nursing Services no later than 12 hours after the occurrence of the accident of incident. 5. Forwarding completed report of incident/accident forms: 2. Submit the original copy of the report of incident/accident form to the Administrator no later than 24 hours after the occurrence of the accident or incident. Facility's policy on Smoking-residents revised August 2008 indicates: Policy statement: to establish and maintain safe resident smoking practices. Interpretation and implementation: Standards: 2. All residents who desire to smoke will have assessment performed by a qualified member of the social service department to determine if they are safe to smoke independently. The assessments will be reviewed by an interdisciplinary team for determination of appropriate interventions, if needed as well as care plan development. 3. Smoking risk assessment are performed upon admission and quarterly or with any changes which could affect the safety of the resident. These assessments are reviewed by the interdisciplinary team for agreement and planning of interventions. 145211 Page 11 of 11