Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observation, interview, and record review, the facility failed to follow their Extreme Weather
Temperature Policy by not maintaining indoor temperatures in the range of 71 degrees to 81 degrees
Fahrenheit. This failure affected 3 residents (R8, R9, R11) in dialysis and 4 residents (R6, R7, R12, R13)
residing on the wing complex.On 1/20/2026 at 11:50AM, during unit rounds, state agency observed
residents in the XXX complex unit hallway wearing multiple layers of clothing, hoodies, zipped up jackets.
State agency and V3 (Assistant Director of Nursing/ADON) continued walking down the hallway of the XXX
complex wing and observed V3 zipping up her blue sweater. V3 stated this hallway is cold. State agency
observed multiple staff wearing zipped up sweaters.On 1/20/2026 PM at 12:03PM, V9 (Maintenance
Director) stated the complex XXX wing heater system was down and the facility called a company to come
and assess the heating system in the end of November. V9 stated after the company came and worked on
the heating issue, it resolved the heating issue to the rooms on the left side of the complex XXX wing, the
odd room numbers, but we are still having heater issues to the resident rooms in the right side of the
complex XXX wing, the even room numbers.On 1/20/2026 at 12:25PM, V10 (Certified Nursing
Assistant/CNA) stated the XXX wing is cold, some of the resident's room heaters are not working.On
1/20/2026 at 12:42PM, V11 (Licensed Practical Nurse/LPN) stated the XXX complex unit, some rooms do
not have proper heating.Record review of the facilities temperature log sheets provided by V1
(Administrator) document dated 1/7/2026 time 7:00AM reads, location Complex by R14's room temperature
was 63.9- degrees Fahrenheit. Temperature log sheet dated 1/8/2026 at 6:00AM documents, location
Complex by R6's room, temperature was 62.1-degree Fahrenheit. Temperature log sheets provided by V1
dated 1/13/2026 time 6:00AM documents, location complex by R13's room temperature was 63.2 degrees
Fahrenheit. Temperature log sheet dated 1/14/2026 at 6:00AM documents, location Complex near R7 and
R12's room, temperature was 60.1-degree Fahrenheit.On 1/20/2026 at 12:53 PM, V9 and state agency
were standing in the XXX hallway between R6's room and the room in front of R6's, V9 measured the
temperature using the (brand name) thermometer and it read 62.2 degrees Fahrenheit.On 1/20/2026 at
12:53PM, V9 and state agency checked the temperature using a (brand name) thermometer and it read
61.9-degree Fahrenheit inside R6's room. At 12:55 PM checked the temperature in R5's room, V9 and state
agency observed that the (brand name) thermometer of R5's room read 62.0-degree Fahrenheit. V9 stated
62.0-degree Fahrenheit in a resident's room is unacceptable and the temperature to the rooms should be
71 to 81 degrees Fahrenheit.On 1/21/2026 at 10:25AM, state agency and V9 went into the dialysis room, in
the XXX complex wing. Observed residents receiving dialysis treatment who were wrapped in multiple
blankets. V9 measured the temperature in the dialysis room using the (brand name) thermometer and it
read 62.2 degrees Fahrenheit.Random interviews were conducted on 1/22/2026, R8, R9, and R11 stated
they received dialysis yesterday and it was cold in there. R9 states the cold makes her body hurt and is
very uncomfortable. R8 stated it was so cold in there, its uncomfortable, it makes R8 angry. R11 stated
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145211
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
01/23/2026
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
the dialysis room is cold, stated she takes two blankets with her and wraps them over her body and head,
states there is no heat in the dialysis room.Policy and Procedure titled: Extreme Weather Temperature
Policy, effective Date: 1/1/2024.Policy reads: Policy: It is the policy of this facility to maintain indoor
temperatures in the range of 71 degrees - 81 degrees Fahrenheit. Interventions will be promptly
implemented to protect residents' health and safety when temperatures fluctuate outside the accepted
range. Policy Specifications: To assure all departments assist in implementing appropriate interventions to
maintain resident comfort during severe exterior temperature changes which may affect interior
environment. Standards:Heating and air-conditions system will be inspected, maintained and repaired in
accordance with the prevention maintenance schedule. The Maintenance Director will advise administration
of any serious malfunctions or need for repairs/replacements beyond the approved budget.3.Repairs of
heating and air-conditioning units will be considered a priority during extreme weather or anticipated
extreme temperature during winter and summer months.
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
01/23/2026
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 follow their Fall Guideline Policy when the
admitting nurse failed to complete the Fall Risk Evaluation upon a resident's admission into the facility. This
affected 1 (R1) resident of 3 reviewed for accidents.R1 is a [AGE] year-old female admitted to the facility on
facility 6/5/2025 at 12:30PM and discharged date on 6/6/2025 at 3:36PM. R1's medical diagnosis are, but
are not limited to, Chronic Obstructive Pulmonary Disease with acute exacerbation, acute respiratory failure
with hypercapnia, type 2 diabetes mellitus, unspecified asthma with acute exacerbation, epilepsy with
status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal
electroencephalogram, other supraventricular tachycardia, hypertension.On 1/21/2026 at 11:11 AM, V16
(Restorative Director) stated the fall assessment evaluation for new admitting residents should be done on
admission by the admitting nurse. V16 states that I do not see an initial fall risk assessment for the date R1
was admitted to the facility.On 1/21/2025 at 11:57AM, V6 (Licensed Practical Nurse/LPN) stated she was
R1's admitting nurse. V6 stated when she got report from the hospital, they stated R1 fell a bunch of times,
was a high fall risk, and R1 was not complaint. V6 stated, she does not recall what assessments she did for
R1. V6 states for an initial fall risk assessment that should be in place upon admission, a fall risk should be
in place to evaluate the resident's fall risk score. V6 stated it is the responsibility of the admission nurse to
complete the fall risk evaluation. V6 stated a fall risk evaluation risk assessment should be completed upon
admission, after a fall, and quarterly. If a fall risk evaluation assessment is not complete, a resident is at risk
of falling.On 1/20/2026 at 1:30PM, V2 (Director of Nursing/DON) stated it is expected for the admitting
nurse to complete the initial fall risk assessment the day of admission. I do not see a fall risk score for the
admission date.Reviewed R1's fall incident report dated 6/5/2025 at 3:15PM, V6 documents a fall incident
description that reads informed by co-nurse the R1 was observed sitting on the floor in room. R1 stated she
needed to go to the bathroom, when asked why she didn't use the call light R1 states I forgot a call light
because I had to use the bathroom really bad.Reviewed R1's fall incident report dated 6/6/2025 at 1:00PM
V14 (LPN) documents a fall incident description that reads R1 as observed on the floor after an
unwitnessed fall head to toe assessment performed by V14 and Nurse Practitioner (NP) a knot observed on
the left side of the resident's head no active bleeding noted. Resident was observed on the floor after an
unwitnessed (fall). Upon assessment R1 stated she was sitting in her wheelchair, and she had reached
down in an attempt to grab her phone and subsequently lost her balance.Reviewed R1's Fall Risk
Observation, effective Date, 06/06/2025 at 2:56PM documents R1's category as High Risk for falls, score of
13.Reviewed Facilities Fall Guideline Policy provided by V2. Policy revised 8/2024 documents: Purpose: to
consistently identify and 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: 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 function. Fall
Risk Evaluation: A fall evaluation is used to identify individuals who have predicting factors for falls. This
evaluation is completed upon admission, quarterly, annually and with significant change in condition.
Purpose: 1. To consistently identify and evaluate residents who fall and to treat or refer to treatment
appropriately. 3. To prevent or reduce injuries related to falls. 6. Individualize interventions for each resident.
1. If the evaluation finds the resident at risk, implement resident specific interventions / precautions.
Event ID:
Facility ID:
145211
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the January 23, 2026 survey of Thryve of Burbank?
This was a inspection survey of Thryve of Burbank on January 23, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Thryve of Burbank on January 23, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.