Health inspection·April 22, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure resident rooms were clean and free of clutter, trash, dust, food particles, soiled linens, substances, and chemical buildup. This failure applied to four of four residents (R1, R2, R3, and R4) reviewed for environment. Findings include: 1. R1 is an [AGE] year-old male with a diagnoses history of Dementia, Parkinson's Disease without Dyskinesia, Traumatic Brain Injury, Chronic Kidney Disease, Urine Retention, Urinary Tract Infections, Dysphagia, Disorder of Muscle, and Blindness in Right Eye who was admitted to the facility 04/16/2025. On 04/21/2025 at 10:19 AM V9 (Family Member of R1) stated yesterday she observed food particles in R1's bed and she observed red stains that looked like blood and the nursing aide told her it was Jello. On 04/21/2025 at 10:34 AM, R1 is in his room sitting on his bed. Observed R1's room floors to be sticky and with some trash on it, several red particles on his bed sheet, and a gown left on his bed. R1's bedside table is sitting in front of him with a sticky substance on most of it. A clean brief is seen sitting in the chair in R1's room, a small cup with a thick cream like substance and a clean brief left sitting on a nightstand near his room window, and a gown and linens left sitting on a taller nightstand near his window. R1's Current Care Plan initiated 04/17/2025 documents he has multiple diagnoses that impede his ability to perform activities of daily living at his prior level of functioning. R1's Current Care Plan initiated 04/18/2025 documents has an ADL (Activities of Daily Living) self-care performance deficit related to a decrease in functional mobility, decreased coordination, decrease in strength, falls/fall risk, increased need for assistance from others and functional limitation with ambulation. 2. R2 is an [AGE] year-old male with a diagnoses history of Encephalopathy, Lung and Brain Cancer, Disorder of Muscle, and Cognitive Communication Deficit who was admitted to the facility 02/20/2025. On 04/21/2025 at 11:34 AM, R2 is observed in his room lying in his bed. R2's blanket is on his bed stained, the nightstand near R2's bed has a pair of latex gloves, multiple greeting cards, a clean brief, a plastic bag, and box of tissue sitting on it. Observed a chair near R2's bed with clothes sitting on the back of it along with multiple heel booties sitting in it. Observed multiple clean briefs sitting on a bedside table against the wall between R2's room closet and his bed. Observed a (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 9 Event ID: 145608 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 145608 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thryve of South Holland 2145 East 170th Street South Holland, IL 60473 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)