Inspection·May 15, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mobility is impaired and has an ADL self-care performance deficit related to partial paralysis and is totally dependent on staff for activities of daily living. 4. R7 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke, Alzheimer's Disease, Dementia, Parkinson's Disease, and Peripheral Vascular Disease who was admitted to the facility 02/23/2022. R7's current care plan documents she has an ADL (Activities of Daily Living) self-care performance deficit related to disease process, Parkinson's Disease, and Partial Paralysis and requires assistance with most activities of daily living. On 05/05/2025 at 10:31 AM R3 stated she sits in her own poop a lot due to having diarrhea and having to wait for hours after pressing the call light. R3 stated she has baby ants in her room. R3 stated when housekeeping mops, they don't mop the areas around or near her bed. Observed small piles of dead ants on each side of her heater underneath her window. Observed R3's and her roommate R7's room floor sticky and R7 lying in her bed with heavy buildup of residue and particles underneath. 5. R4 is a [AGE] year-old male with a diagnoses history of Anxiety Disorder and Quadriplegia who was admitted to the facility 03/21/2014. R4's Current Care Plan documents he has an ADL (Activities of Daily Living) self-care performance deficit related to Activity Intolerance and Quadriplegia and is totally dependent on staff for activities of daily living. The facility's Wound Report dated 05/05/2025 documents R4 has a moisture associated incontinence wound to his right posterior thigh that is facility acquired and was identified 04/25/2025. Grievance forms from January - April 2025 document concerns on 01/03/2025 regarding long call light response; on 01/08/2025 regarding call light response time and incontinence care; on 01/13/2025 regarding housekeeping, activities of daily living regarding changing the resident and the residents linens; feeding assistance; on 01/27/2025 regarding food quality; on 03/11/2025 regarding showers/bathing/grooming, incontinence care, and not having bed linens; on 03/24/2025 regarding showers, housekeeping, and assistance with activities of daily living of dressing resident; on 03/28/2025 regarding call light response time; and on 04/22/2025 and regarding incontinence care and ants. On 05/14/2025 1:35 PM V2 (Director of Nursing) stated indicators of not enough assistance with activities of daily living would include poor grooming, cleanliness of rooms, body odors, their appearance etc. V2 stated multiple complaints regarding activities of daily living lead to in-services, monitoring the residents care more closely via observations and documentation. V2 stated he identifies trends in issues through observations of call lights ringing, poor grooming, and other nursing care observations as well as nursing reports. V2 stated R4 has a moisture associated wound because he uses a catheter but refuses to have it at night and he can't feel when he's wet. V2 stated to prevent R4 from developing a wound barrier cream is applied overnight, and staff are instructed to still conduct rounds and check him at night although he doesn't wish to be woken up. V2 stated R4 requires more frequent incontinence checks to prevent a wound from developing. V2 stated R4 has never refused incontinence care. On 05/14/2025 at 1:35 PM V2 (Director of Nursing) stated housekeeping may not have returned to cleaned up the piles of dead ants in R1 and R3's rooms after pest treatment was provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 2 of 8 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 05/15/2025 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)

F 0677 The facility's ADL (Activities of Daily Living) policy dated 02/2023 and received 05/15/2025 states: Level of Harm - Minimal harm or potential for actual harm In accordance with the comprehensive assessment, our facility provides care and services for the following activities: Hygiene (bathing, dressing, grooming). Residents Affected - Some The facility's Housekeeping Services Policy received 05/15/2025 states: It is the policy of this facility to maintain a clean environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable, and homelike environment. Policy Specifications: To ensure that the facility and resident rooms are maintained in a sanitary manner; to provide a comfortable environment. Responsibility: Housekeeping Supervisor and Housekeeping Personnel. The department shall routinely clean the environment of care, to keep the facility free from the accumulation of dust, rubbish, and dirt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 3 of 8 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 05/15/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interviews and record reviews, the facility failed to provide adequate supervision for residents who are at risk for falls, with a history of falling; and they failed to implement effective fall interventions. This failure applies to two of two residents (R5 and R6) reviewed for falls. Findings include: R5 is a [AGE] year-old male with a diagnoses history of Vascular Dementia; Peripheral Vascular Disease, Metabolic Encephalopathy, Presence of Cardiac Pacemaker, and Lack of Coordination, who was admitted to the facility 01/06/2024. On 05/06/2025 at 9:53 AM R5 in observed in his room lying in his bed in the lowest position with confusion and his call light closed up in his nightstand drawer behind him. R5's Current Fall Care Plan initiated 03/02/2024 documents he has history of falling related to altered thought process, poor safety awareness, restlessness, and impaired mobility with interventions initiated 03/02/2024 of Give resident verbal reminders not to ambulate/transfer without assistance; widen and extend bed; intervention initiated 03/04/2024 of Keep bed in lowest position with brakes locked; intervention initiated 03/08/2024 of observed frequently; interventions initiated 05/03/2024 of Attempt to keep resident on the same routine; Keep resident in view during high risk times if possible; intervention initiated 09/09/2024 of bolsters and floormates in place; intervention initiated 01/27/2025 of Educate patient to ask for assistance to retrieve dropped items; intervention initiated 02/10/2025 of Monitor for proper positioning while in bed; intervention initiated 03/07/2025 of When resident shows signs of restless, staff will transport resident to nursing station for close monitoring; intervention initiated 03/11/2025 of Engage resident in activities of his liking to keep occupied; intervention initiated 04/04/2025 of When up in geriatric wheelchair keep reclined for safety, due to poor trunk control; and intervention initiated 04/06/2025 of provide comfort and repositioning when restless in bed. R5's Current Care Plan initiated 08/01/2024 documents he displays moderate impairment with daily decision making and requires cues and supervision with interventions of Provide cues, assistance, and supervision with ADLs (Activities of Daily Living) and all facility activities. R5's Current Care Plan initiated 04/06/2025 documents he doesn't have much active movement and requires dependent assistance from staff with interventions including monitor the patient throughout the shift more often; Keep resident clean and dry throughout the shift; Help with ADL care and assist with feedings; Keep resident near nursing station for frequent monitoring. R5's Current ADL (Activities of Daily Living) Care Plan documents he has an ADL self-care performance deficit related to Disease Process, Nervous System Inflammation, Impaired balance, and Limited Mobility and is totally dependent on staff for activities of daily living. R5's progress note dated 12/10/2024 at 4:19 PM documents the nurse observed him lying on the floor on his right side next to the wheelchair in the lounge area and he stated, he tried to transfer from the wheelchair to another chair. R5's Fall Risk Management Report dated 12/10/2025 documents he experience an unwitnessed fall in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 4 of 8 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 05/15/2025 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)

F 0689 the lounge. Level of Harm - Minimal harm or potential for actual harm R5's Fall Risk Management Report dated 01/23/2025 documents he had an unwitnessed fall in the dining room while trying to pick up glasses. Residents Affected - Few R5's progress note dated 2/10/2025 at 02:30AM documents he was observed on the left mat next to the bed and was placed back in bed by two aides. R5's Fall Risk Management Report dated 02/10/2025 documents he had an unwitnessed fall in his room and stated he slipped out of bed. R5's progress note dated 3/6/2025 at 02:00 AM documents he was observed lying on the floor mat on the left side of the bed and was picked up and placed in bed with a mechanical lift. R5's Fall Risk Management Report dated 03/06/2025 documents he had an unwitnessed fall in his room and stated he rolled out of his car. R5's progress note dated 3/11/2025 at 12:24 PM documents Writer was called to the lounge by staff and upon entering R5 was observed on floor near his geriatric wheelchair on his right side. Writer asked R5 what happened, and he stated, I just slipped. R5 was placed back in geriatric wheelchair and was positioned in front of nursing station for close monitoring. R5's Fall Risk Management Report dated 03/11/2025 documents he had an unwitnessed fall in the lounge. R5's progress note dated 4/4/2025 at 9:25 PM documents he fell out of the wheelchair in the hallway, after lunch. R5's Fall Risk Management Report dated 04/04/2025 documents he had an unwitnessed fall in the hallway near the nurses station and may be tired of staying in the wheelchair for a long period of time. R5's progress note dated 4/6/2025 at 3:24 PM documents he was observed lying supine on the floor and when asked what happened resident stated I don't know, I'm just on the floor. R5's Fall Risk Management Report dated 04/06/2025 documents he had an unwitnessed fall in his room. R6 is a [AGE] year-old female with a diagnoses history of Epilepsy, Hypotension, Stroke, Disorder of Muscle, Abnormal Posture, Abnormalities of Gait and Mobility, Lack of Coordination, and History of Falling who was admitted to the facility 12/10/2024. On 05/06/2025 at 9:46 AM Observed R6 in her room alone standing with one pant leg on the wrong leg attempting to put on her pants. Observed R6 to be crying and stating she was upset with her daughter because she forgot about her on Mother's Day. Observed R6 with her right foot bare and left foot with a sock on. R6's Current Care Plan initiated 12/10/2024 documents The resident is at risk for falls related Gait/balance problems, Incontinence, Unaware of safety needs with interventions initiated 12/10/2024 of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Ensure the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 5 of 8 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 05/15/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is wearing appropriate footwear when ambulating or mobilizing in wheelchair; Follow facility fall protocol; intervention initiated 03/03/2025 of educate resident to ask for assistance with dressing needs; intervention initiated 03/08/2025 of educate patient to lock wheelchair brakes; and intervention initiated 04/08/2025 of Anticipate and meet The resident's needs. R6's Current Care Plan initiated 12/12/2024 documents she has an ADL (Activities of Daily Living) self-care performance deficit related to arthritis, high cholesterol, stroke without residual deficit, atrial fibrillation (irregular heartbeat), therapy, seizures, cirrhosis, gastrointestinal blood vessel condition, hypertension, and heart medications and requires assistance most activities of daily living. R6's Current Care Plan initiated 01/23/2025 documents she is limited in ability to transfer herself related to weakness and requires a restorative transfer program. R6's Current Care Plan Initiated 03/04/2025 documents she is resistive to care related to adjustment to nursing home and thinking she does not need assistance with ADL care with interventions including Allow the resident to make decisions about treatment regime, to provide sense of control; Encourage as much participation/interaction by the resident as possible during care activities. R6's Fall Risk Management Report dated 12/17/2025 documents she had an unwitnessed fall in her room and was found lying on her left side next to her bed. R6 stated she was reaching for the call light when she fell. R6's progress notes dated 1/9/2025 at 03:00 AM documents she was observed sitting on her buttocks on the side of her bed. R6's Fall Risk Management Report dated 01/09/2025 documents she had an unwitnessed fall in her room, the nurse on duty responded to the call light and R6 was found sitting on her buttocks on the floor next to her bed and stated she was getting ready to go to the bathroom but denied falling. R6's progress notes dated 3/1/2025 at 01:02 AM documents she was observed on the floor. R6 stated she was trying to put her pants on and slid on the floor. R6's Fall Risk Management Report dated 03/01/2025 documents she had an unwitnessed fall in her room and was observed sitting on the floor in front of the wheelchair. R6's progress notes dated 3/8/2025 at 08:00 AM documents the nurse was summoned to R6's room and observed her sitting in front of her wheelchair. R6 stated she was reaching for her pull-ups and slid to the floor. R6 was placed back in her bed with two person's assistance. R6's Fall Risk Management Report dated 03/08/2025 documents she had an unwitnessed fall in her room. R6's progress notes dated 4/8/2025 10:16 PM documents she was observed lying near the end of the bed on the floor. R6 has to be constantly re-educated throughout the day to use assistive devices, walker or wheelchair. Family came to visit and she was fine. When the family left, she wanted to get out of her chair to use the restroom. R6 was placed back in bed and attempted to get up again. R6 refuses to use the call light, refuses to stay in bed and follow simple direction from staff. R6's Fall Risk Management Report dated 04/08/2025 documents she had an unwitnessed fall in her room attempting to use the bathroom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 6 of 8 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 05/15/2025 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)

F 0689 R6's census report documents her room was changed on 04/10/2025. Level of Harm - Minimal harm or potential for actual harm R6's progress notes dated 4/30/2025 at 03:24 AM documents there was a noise heard in room; R6 was observed on the floor lying on left side and placed back in bed per facility protocol. Residents Affected - Few R6's Fall Risk Management Report dated 04/30/2025 documents she had an unwitnessed fall in her room and stated she slid out of bed. R6's progress notes dated 5/2/2025 at 08:30 AM documents This Writer was called to R6's room and upon entering the room she was noted sitting on the floor in a small space between the bed and the wall. When asked what happened R6 stated that she was trying to get her shoe off the floor. (R6's shoes were on the other side of the bed). R6 was assisted off the floor into the bed. R6's Fall Risk Management Report dated 05/02/2025 documents she had an unwitnessed fall in her room. The facility's fall reports from December 2024 - May 2024 documents 86 unwitnessed falls with R5 and R6 each having 7 unwitnessed falls. On 05/14/2025 at 1:35 PM V3 (Restorative Nurse/Licensed Practical Nurse) stated she is the fall coordinator which includes care plan reviews, quality assurance investigation for every fall ensuring all components are in place, and audits fall interventions and equipment. V3 stated the facility does not provide one on one observation or monitoring, nor use restraints or fall alarms. V3 stated R5 is very confused and has very poor safety awareness and staff would not be able to reach him quick enough to prevent a fall. V3 stated R5 is very impulsive and falls just happen. V3 stated one of R5's falls were due to him reaching for his glasses that were already on his face. V3 stated you can't prevent a fall and they have a right to fall. V3 stated you can modify fall care plans when asked by surveyor how can falls be prevented. V3 stated she wouldn't say R5 requires more supervision than the facility can provide and he's like a lot of the facility's patients with dementia with impulsivity and safety awareness. V3 responded absolutely when asked by the surveyor if the facility's goal is to prevent falls. When asked by the surveyor if a resident continues to have repeated falls what does that indicate. V3 responded we continue to address the plan of care and put in an intervention that will prevent that fall. V3 stated R6 does not like coming out of her room so that was an issue, and one recent approach was having activities to go in her room and offer her one to one and we also did a room change where she was moved directly across the nurses station for closer supervision. V3 stated R6's previous room is down the middle hall almost the furthest away from the nurses station. V3 stated she did a restorative modification for R6 for transfers because many of her falls were due to attempt to self-ambulate without assistance. V3 stated R6 is very confused, she has good and bad days and there are days where she doesn't recall time, place, or year and there are times where she is more alert but won't recognize that she has had incontinence episode. V3 stated R6 does not have good awareness of her physical limitations where she thinks she can walk without assistance when she can't and during restorative therapy they do a lot of safety cueing with her. V3 stated R6 refuses care and thinks she can do things for herself and she refuses medications. V3 stated R6 is definitely impulsive and so used to doing everything on her own and caring for everyone else she doesn't know how to accept that kind of help from others. V3 stated R6 has a deficit that is either related to a psychiatric diagnosis or cognitive impairment. When asked by surveyor how can staff monitor R6 adequately from outside her room, V3 stated constant cueing when they see R6 while walking by the rooms and staff do go in and check on her constantly and anticipate her needs. V3 stated she considers R5 and R6's fall interventions successful due to the root causes of her falls constantly changing. V3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 7 of 8 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 05/15/2025 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)

F 0689 stated attempting a routine would be an appropriate fall intervention for R6. Level of Harm - Minimal harm or potential for actual harm On 05/14/2025 at 1:35 PM V2 (Director of Nursing) stated if the fall incident listed on the fall report does not have a Y marked under the section for witnessed, it is an unwitnessed fall however it does not categorize those falls under the unwitnessed fall category due to the way in which the incident is logged in the system. V2 stated if residents continue having incidents despite constant attempts to modify interventions this may indicate they need to be transferred to another facility that may provide one on one care or more supervision. V2 stated if R5 has multiple falls the same way that's when he would say fall interventions are unsuccessful. V2 agreed all of R5's falls have the common theme of him attempting to move and stated R5 attempts to do things on his own. V2 stated R5 has some trunk control and uses a geriatric wheelchair. V2 stated the primary cause of R5's falls is him trying to do things on his own and he doesn't have the cognitive awareness that he is not capable of performing these activities independently. V2 stated R5's mental and physical abilities are not on the same level and a lot of time this is the root cause of his falls. V2 could not explain what an effective intervention would be for this behavior and he doesn't think there is an applicable intervention for this behavior. V2 stated if R5 has his call light he believes he can use it although he may not be sure of what he is using it for, and his call light should be in reach. V2 stated it is important to keep commonly used items in reach for R5 and other residents. V2 agreed all of R6's falls are related to attempting to perform activities of daily living and she doesn't understand she needs to ask for assistance. V2 stated R6 has intermittent confusion and at night she heavily Sundowns. V2 stated the right to fall means the facility can't restrain them from moving. V2 stated if staff observe R5 trying to get up staff should respond as soon as possible and attempt to assist him. V2 stated you would want to increase observations, when R5 is out of bed to ensure he is where he can be easily seen. V2 stated if a resident falls in common areas it could be asked if there were staff present and if so where were they located. V2 stated an indication that fall interventions for R5 or R6 are effective would be a reduction in falls, and not having the same type of falls or falling due to the same causes or contributing factors. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 8 of 8