Health inspection·January 11, 2026

F 0689 Level of Harm - Actual harm Residents Affected - Few approximately 7:30 PM, and someone was in the room to assist R1, and disconnected the call. R1's family member said that R1 never complained or said that she was not feeling well, and around 10:30 PM, he received a phone call to come to the facility. The family was not able to see R1 and only touched R1 over the bag and spoke with the police, and did not communicate with staffing on the incident. R1's family member said that R1 fell because only one nursing assistant provided care to her, and she required 2 nursing assistants. R1's family member said I did not get the death certificate yet. I do not know if the death was of a natural cause. I have many questions on how R1 was assessed and when CPR was initiated. Following the fall, R1 became unresponsive, and CPR was initiated by EMS. The facility was awaiting the coroner's report at the time of the survey. The relationship between the fall and the resident's death could not be determined at the time of review. 2. R2 is [AGE] years old resident admitted to the facility on [DATE] with the diagnoses including, but not limited to hypoxic ischemic encephalopathy, respiratory failure on a ventilator/tracheostomy, acute embolism and thrombosis of the femoral vein, thoracic aortic aneurysm, and R2 is incontinent of bowel and bladder and receives enteral nutrition. Facility reported incident documents that on [DATE], R2 was observed lying on his back on the floor beside the bed. A laceration was noted on the left side of the head with active bleeding a scratched noted on the left side of the neck. R2 was sent to a local hospital. Hospital records reviewed, and R2 had a laceration to the left scalp requiring three staples and a left shoulder contusion. Minimum Data Set (MDS) assessment of [DATE] documents the following:Section C 1000(Cognitive skills for daily decision making) score is 3 (indicating severe impaired decision making)Section GG: R1 is dependent on toileting hygiene, rolling left and right, shower, oral care, dressing, and lying to sitting. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On [DATE] at 12:22 PM V13 (Certified Nursing Assistant) said, I was doing rounds, and I was giving R2 peri-care by myself. R2 was at the edge, and he fell out of bed towards the door. I turned R2, and he slid out of bed. R2 required two person assist but I could handle him by myself. I could do it myself, and I had been doing that. I was suspended for not having 2 assists. I have received education after. I know that I was supposed to provide care with two, but I did with one. I know now, and I follow the care plan. V12's (Registered Nurse)[DATE] nursing notes stated, I was called into the room by V13, and during patient care, due to the resident having a fall with injury to the left side of his head. The resident left the facility with 911 emergency assistance, going to a local Hospital for evaluation. Upon assessment, the R2 was noted lying on his bedroom floor next to the bed on his back. R2 had a laceration to the back left side of his head with active bleeding. I cleaned the site and wrapped it with a fluff gauze roll and 4x4 to stop the bleeding. R2 also had a scratch on the left side of his neck that was cleaned and bandaged to prevent infection. Pupils not responsive to light, skin was warm to the touch. R2 was alert to self, remains non-verbal. Trach to ventilator stable. Heart rate elevated at 110, blood pressure 128/63, respirations 24. The responsible party was made aware of the condition and transfer. On [DATE] at 2:34 PM, V9 (Restorative Director/Licensed Practical Nurse), said both R1 and R2 fell out of bed while receiving care, and both residents were supposed to have 2 assists instead of one. Both certified nursing assistants provided care alone, resulting in falls. On [DATE] 2:54 PM, V2 (Director of Nursing), I expected the staff follow the care plan and ensure the safety of residents. V2 said, I understand that based on MDS (Minimum data set) assessment, both resident R1 and R2 required 2 assists during care, and one nursing assistant provided care. I provided education to the staff to follow the plan of care. Facility policy titled, Fall Guide (revised on 8/2024), which includes: Purpose: To consistently identify and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145211 If continuation sheet Page 2 of 3 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 145211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thryve of Burbank 5400 West 87th Street Burbank, IL 60459 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately, and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.To rehabilitate residents to their fullest potential of functionFalling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface. The fall may be witnessed, reported by the resident or an observer, or identified when a resident is found on the floor or ground. Falls include any fall, regardless which setting it may have occurred.The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:1. Identification of hazards and risksEvaluationImplementationMonitoringAnalysis Event ID: Facility ID: 145211 If continuation sheet Page 3 of 3