Health inspection·April 3, 2025

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility has failed to follow their fire watch policy by not reporting to IDPH (Illinois Department of Public Health) that the sprinkler system is not working in all four units of the facility. This has the potential to affect all 117 residents residing at the facility. Residents Affected - Many Findings Include: Facility's census dated 4/3/25 denotes 117 residents. Facility Fire Watch Policy denotes to establish a process for fire safety in the event that the fire protection system fails or is not operating (includes service being performed on system). When the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Facility incident report dated 1/23/25 denotes on 1/22/25 description of occurrence: Facility is on Fire Watch related to broken pipe. Fire Dept (Department) has been made aware. Occurrence resolution: Facility on Fire Watch related to a broken pipe. The broken pipe affected the sprinklers on one unit only. 1/28/25 Fire protection plumbing company A came out and fixed the pipe and reconnected the sprinklers on the one unit. Facility incident report dated 1/29/25 denotes description of occurrence: Facility is on Fire watch related to sprinkler system on one unit being offline. Fire department has been made aware. Fire plumbing company B will be in 1/30/25 to address the issue. Occurrence resolution: Facility is on Fire Watch related to sprinkler system on one unit being offline. Fire department is aware. Fire protection plumbing company B came out 1/30/25 and identified the issue are awaiting on part to be delivered. Facility incident report dated 2/3/25 denotes description of occurrence: Facility is on Fire watch related to sprinkler system on one Long term care unit being offline. Fire department has been made aware. Occurrence resolution: Facility is on Fire Watch related to sprinkler system on one unit being offline. Fire department is aware. Fire protection plumbing company B came out 1/30/25 and are awaiting on part to be delivered. On 4/2/25 at 6:30 pm, V2 (Maintenance Director) stated he has been a maintenance director for 15 years and this facility for over a year. V2 stated a pipe that was in the back of the building over the laundry room froze then busted on 1/22/25 and one unit of the facility was effected however that Page 1 of 2 145608 145608 04/03/2025 Thryve of South Holland 2145 East 170th Street South Holland, IL 60473

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many unit was vacant of residents. V2 stated the Fire Department came and they were instructed by the local fire department to go on Fire Watch until issue could be resolved. V2 stated they called the plumbing services (A) and they came to fix the broken pipe. V2 stated on 1/29/25 another pipe busted and it affected the Medicare unit where residents did reside. V2 stated the local fire department came and told them to continue the Fire Watch program. V2 stated at that time he was instructed by corporate to use fire protection plumbing company B instead of the one they were contracted with before. V2 stated they contacted fire protection plumbing company B that he was instructed to use by corporate and they came to the facility the next day on 1/30/25 to assess the situation. V2 stated he was told by fire protection plumbing company B that the clapper for the sprinkler needed to be changed out in order to fix that part of the sprinkler system and they would order it. V2 stated on 2/3/25 a couple of sprinkler heads started leaking in the long term unit where residents resided. V2 stated the local fire department came to the facility and told them to stay on fire watch until the sprinkler system is fixed. V2 stated fire protection plumbing company B came out to the facility that day also. V2 stated fire protection plumbing company B drained the water from the whole sprinkler system which included the long term care unit, memory care unit, the Medicare unit, and the vacant unit. V2 stated fire protection plumbing company B told them there was nothing they could do until the parts came in. V2 stated the fire alarm system never malfunctioned until after 3/2/25 when the fire alarm panel was sending false alarms to the emergency call center and then the local fire department would come to the facility. V2 stated the main issue with the sprinkler system is that the clapper in the sprinkler head was damaged. V2 stated the part was supposed to be delivered to fire protection plumbing company B 3/28/25 but got notice on 4/3/25 from them that the part will not be available until mid-May. V2 stated they have been doing fire watch and have to walk the whole building every 30 minutes and log it. V2 stated after hours when maintenance is not in the facility the nurse managers on duty do the Fire Watch and log it in the Fire Watch book. V2 stated the roof had never caved in or was structurally damaged from the leaking pipes. V2 stated they did have to put up new drywall in the ceilings where the pipes had leaked. On 4/3/25 at 6:15 pm, V1 (Administrator) stated they were instructed by corporate to use fire protection plumbing company B to service the sprinkler system and fire alarm panel instead of fire protection plumbing company A that the facility was using and were contracted with before. V1 stated she is responsible for reporting the facility incidents which included the incidents that happened related to the leaking pipes of the sprinkler system to IDPH. V1 stated when she sent the incident reports on 1/23/25 and 1/29/25 she did not name the specific unit that was affected by the sprinkler system but did on the 2/3/25 incident report. V1 stated did not remember or recall if she included in her last incident report sent to IDPH on 2/3/25 that she included that all four units in the facility do not have a working sprinkler system and the duration. 145608 Page 2 of 2