Inspection·August 1, 2025

F 0641 Level of Harm - Potential for minimal harm Residents Affected - Some code 0 which indicates No by V10 (Minimum data set, MDS nurse). R45's Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months documents a code 0 which indicates No by V10. On 7/31/25 at 11:03AM, V10 said for any resident receiving hospice services their Minimum data set (MDS) should reflect that hospice services are being received in section J if paperwork is available. V10 said section J1400 should be marked a yes for R45 after reviewing the hospice certification signed 4/23/25 for MDS on 4/28/25 and 7/30/25. 4. On 07/31/2025 at 1:02 PM V15, LPN (Licensed Practical Nurse), said Resident R113 is on hospice. V15 said both the nurse and the CAN (Certified Nurses Assistant) were here to see her today, I saw them. On 7/31/25 at 1:08PM V9, MDS Nurse, said R113 was not marked Hospice on her MDS due to an error on our part. Review of R113's care plan includes intervention for her hospice care plans. Review of R113's census states she is on hospice. Review of R113's MDS May 2025 has no 0 for hospice. R113 Hospice Certification and Plan of Care states start of care 1/17/2024. 5. R18's diagnosis face sheet does not include Bipolar diagnosis or ICD9 code. R18's MDS dated [DATE] Section I I5900 Bipolar diagnosis is marked. The surveyor requested documentation of R18 diagnosis of Bipolar. On 7/31/25 V15 said she cannot find a written diagnosis. 07/31/2025 11:15 AM V2 (DON/Director of Nurses) said R18 is not Bipolar, she does not have a diagnosis of Bipolar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 2 of 9 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 08/01/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews and records reviewed the facility failed to obtain PASARR (Preadmission Screening and Resident Review) screening for one resident (R30) with diagnosis of Intellectual Disability. This affected one of three resident s (R30) reviewed for PASARR. This failure has resulted in a delay to move R30 to another facility. The findings include:On 7/29/25 at 12:15PM the surveyor attempted to speak with R30. R30 only said hello but would not verbally respond. R30 only shrugged her shoulders and turned away.On 7/29/25 at 11:24AM V13, Ombudsman, said R30‘s family has been waiting for a PASSR II to be done get her transferred to another facility. V13 said the family has been waiting for over 2 months.On 07/30/2025 at 1:15PM V8, Senior Social Service Director, said in May she called and asked about the PASSR II to be completed for R30. V8 said she was told that R30 requires a different PASSR II to be done and they have to send a state person out to do it. V8 said they didn't give her a turnaround time. On 7/30/25 at 11:52AM V1, Administrator, said we are trying to get a level II for R30. V1 said the family wants to move her to another facility, but the facility won't accept her until the Level II PASSR is completed.On 7/31/25 at 1:37PM the surveyor contacted V18, PASSR Help Desk. V18 said the level II requires an external assessment and this cannot be completed until the facility enters the correct information related to R18's prior community address. V18 said currently the facility has listed the facility address, and this is incorrect. V18 said once this is corrected, we can get her screening done, and it usually takes about 2 weeks. V18 said without the previous address we cannot complete the screening. (The call with V18 lasted 5 minutes, enough time to be told the information in the portal needs to be corrected.)Most recent PASSAR was completed for R30 on May 29, 2025 indicating referral for level II.Progress note dated 5/20/25 states pending accepting facility notified facility a level 2 screen related to R30's diagnosis of intellectual disability.Progress note dated 6/24/25 states writer contacted PASSAR assessment company regarding Level 2. Writer was notified that R30 required a state representative to perform the screening. (Last note over 30 days since contacted.) Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 3 of 9 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 08/01/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation interview and record review, the facility failed to prevent an avoidable wound for R32 who was identified as high risk for skin breakdown and dependent on staff for turning and repositioning, and failed to ensure air mattress pumps were appropriately set to the resident's weight per manufacture recommendations. This affected three of three residents (R32, R3, and R64) all reviewed for pressure ulcer prevention. This failure resulted in R32 having a facility acquire stage (3) three pressure wound of the left ear measuring 1.00 cm (length) x 0.50 (width) x 0.00 (depth).Findings include: Residents Affected - Few R32's Braden scale for predicting pressure sore risk dated 6/26/25 documents: high risk. Mobility: very limited: makes occasional slight changes in body or extremely position but unable to make frequent or significant changes independently. Nutrition: adequate. Friction and Shear: problem: requires moderate to maximum assistance in moving. Tissue test dated 6/27/25 documents: Resident requires more frequent turning and positioning then every 2 hours: No. Minimal data set section GG (functional abilities) date 7/2/25 documents: dependent with rolling left and right. Wound assessment detail report dated 7/30/25 documents: Wound: left ear, Status: active, Type: trauma, Classification: abrasion, Source: facility acquired. Date Identified: 7/30/25 Clinical Stage: partial thickness, Exudate: Scant: Type: serous (clear, watery fluid), Measurement: 1.00 cm (centimeters) x 0.50 cm x 0.00cm (LengthxWidthxDiameter). Progress note dated 7/30/25 documents: Noted abrasion to left ear, 100% red, small amount, no odor, serous drainage and intact. On 07/30/2025 1:39 PM, R32 was observed in bed on laying on the right side towards the door with the call light cord across the upper left body, laying on chest and clamped on the right side of her gown. R32 had an opened boarder gauze dressing on the left ear dated 7/30/25. V6 (nurse) removed the opened dressing. R32 was observed with an open area on the left upper cartilage of her ear that was white on the open outer portion of the opening and red in middle. V6 (nurse) said, R32 did not have this wound yesterday. V6 said, R32 has a facility acquired pressure stage two ulcer to the ear. On 7/31/25 at 10:36am, V5 (wound nurse) said, when she entered R32's room yesterday. R32 was down lower in the bed, R32 was lying on a pillow without a pillowcase. R32's left ear wound is facility acquired. R32's wound could be caused by trauma or pressure. R32's wound came from R32 laying on the pillow without a pillowcase. V5 said, R32's wound was caused by the top of the fabric folds when it was gathered under R32's head. On 7/31/25 at 10:54am, V11 (CNA/Certified Nurse's Assistant) said, R32 is dependent on staff for being turned and repositioned. V11 said, when she did her wound rounds with V5 yesterday when they found R32's left ear wound, R32 was in bed, facing the window, on her left side, on the air mattress and her head was not on the pillow. V11 said, R32's pillow had a pillowcase on it. V11 said, when R32 was turned she saw R32 with a white area on the cartilage (curved prominence of cartilage located on the outer ear) of the left ear that wasn't there the day before. On 7/31/25 at 11:09am, R32 was observed in bed laying on the right side towards the door with the call light cord across the upper left body, laying on chest and clamped on the right side of her gown. V5 said, this is the pillow R32 had in place yesterday. V5 removed the pillow from R32's head. V5 removed R32's pillowcase. R32's pillow was observed with a blue loosely covered outer plastic soft pillow. R32's pillow was observed without thick seams consistent with R32's left ear wound indentation. The plastic covering on R32's pillow was easily gathered and moveable. V5 gathered the plastic to demonstrate the folds/creases that R32 was laying on when she found the wound. V5 said, when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 4 of 9 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 08/01/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few entered the room yesterday, R32 wasn't laying on any cords. V5 lifted R32's call light cord and placed it above (without touching the wound) R32's wound in the same direction of the wound. V5 said, R32's wound has a similar width measurement as R32's call light cord. V5 said, R32's wound was classified as an abrasion until the wound doctor visits. V5 said, R32 was not turned every two hours as required to prevent her ear wound. On 7/31/25 at 11:37am, V5 (wound nurse) said, R32's wound on the ear was avoidable. On 7/31/25 at 12:20pm, V3 (DON/Director of Nursing) said, R32's left ear wound came from not being turned and repositioned by staff. V20's (Wound Doctor) Wound Physician Evaluation dated 8/1/25 documents: Stage (3) three pressure wound of the left ear full thickness. Etiology: Pressure. Pressure/Skin Breakdown – clinical protocol dated 1/2017 did not apply. 2. On 7/29/25 at 11:18AM R3 was seen in bed. Air mattress pump was at 200. R3 nonverbal to respond. On 7/30/25 at 10:15AM accompanied by V5, R3's air mattress observed at 200. V5 said it is set at 200 pounds. Record reviewed R3 most current weight is 117 pounds. On 7/29/25 at 10:52 am observed R64 in bed. R63 not answering surveyors questions. Air pump on mattress set at 280. On 7/30/2025 10:15AM accompanied by V5, Wound Nurse, observed and said R64's air mattress is set at 280 pounds. R64's current weight in her chart is 63.6 pounds. On 7/30/25 at 10:17AM V5, Wound Nurse, said the mattress is not benefiting the patients at risk for pressure ulcers if they are at the wrong settings. On 7/30/25 at 10:41AM V12, Maintenance, said our department puts out the mattress. V12 said the settings on the mattress are set according to the residents' weights. If the setting is too high then it's too hard. If it's too low it's too soft. V12 said I will be in servicing my staff on how to properly set the mattress. We don't have a policy for this. I was told how to set the mattress by the nurses. On 7/30/25 at 1:03PM V5 said R64 is at risk for pressure ulcers. She has a history of contractures. V5 said R3 is at risk for developing pressure ulcers. She has contractures that contribute to her risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 5 of 9 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 08/01/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, the facility failed to follow their urinary catheter care policy for indwelling catheter by not securing it to the residents leg. This affected one of one resident (R32) reviewed for catheter care. Findings Include: R32's physician order sheet dated 7/30/25 documents: Catheter in place for diagnosis for Neurogenic Bladder. On 07/30/2025 at 1:39PM, R32 was observed lying in bed on her left side with her indwelling catheter tubing positioned in between R32's posterior legs towards R32's buttock with brown stains on the folded statlock (indwelling catheter stabilization device designed to minimize catheter movement and accidental removal) on the tubing and not secure onto R32's leg. V6 (Nurse) said, R32's indwelling catheter was not secure to R32's leg and the statlock is dirty and undated. V6 said, R32's catheter should secured and clean. V6 said, she would replace the statlock today. On 7/31/25 at 10:31AM, V2 (Director of Nursing/DON) said, he expects staff to follow the facilities urinary catheter care policy. V2 said, indwelling catheters should be secure to the resident's legs with a statlock for stabilization. Urinary Catheter Care dated 2005 documents: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to resident's inner thigh. Event ID: Facility ID: 145608 If continuation sheet Page 6 of 9 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 08/01/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to follow their policy and practice to ensure that medications are labeled with an open and expiration date, failed to ensure all medication was stored in a package with a label, and failed to remove expired medication from the medication cart. This affects six of six (R56, R97, R51, R5, R88, R55) residents and has the potential to affect all residents' that use house stock medication from the facility. On 7/29/2025 at 2:26pm during observation of the medication carts on unit 300, with assist from V2 (Director of Nursing) The following was observed: R56's Lantus Insulin pen had a dispense date of 12/5/2024, there was no open date or expiration noted on the pen. V2 said insulin expires 28 days after opening. House stock acidophilus capsules had a manufactures expiration date of 5/2025. House stock Bisacodyl 5mg (milligram) tabs had a manufactures expiration date of 6/2025. There were thirteen tan colored pills in a clear medicine cup, no label noted, V2 could not identify the pills. R97's Latanoprost eye drops did not have an open date or expiration date. V2 confirmed that the medication was in use for R97. V2 said he has to determine what the expiration date is for the eye drops. R51's Latanoprost eye drops did not have an open date or expiration date. V2 confirmed that the medication was in use for R51. R5's Aspart Insulin pen did not have an expiration date noted on the label. V2 said the insulin pen should have an expiration date noted, V2 confirmed that the pen is in use for R5. R5's Lantus insulin pen did not have an expiration date noted on the label. V2 said the insulin pen should have an expiration date noted, V2 confirmed that the pen is in use for R5. On 7/29/25 at 2:45pm, the medication cart on unit 100 was observed with V6 (Licensed Practical Nurse). Magnesium Oxide 400mg tablets had a manufactures expiration date of 6/2025.On 7/9/25 at 3:02pm, the medication cart on unit 200 was observed with V19 (Registered Nurse). R88's Latanoprost eyedrops had an open date 6/9/2025 and expired date 7/2/2025. R55's Incruse inhaler (umeclidinum) had an open date 5/29/2025, no expiration date noted. V19 said inhalers expire 28 days after opening. Facility policy titled Storage of Medications effective date 10/25/2014 denotes in-part medications and biologicals are stored safely securely and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible only by licensed nursing personnel pharmacy personnel or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Medication label for individual residents are stored separately from floor stock medications when not in the medication card. Expiration dating expiration dates of dispense medications shall be determined by the pharmacist at the time of dispensing. Drugs dispensed in a manufacturers original container will be labeled with the manufacturer's expiration date. Certain medication or package types such as IV solution multiple dose injectable valves are found mix nitroglycerin tablets blood sugar testing solutions and strips once open require an expiration date shorter in the manufacturers expiration date to ensure medication purity and potency. Drugs dispensed in the manufacturers original container will carry the manufacturers expiration date. Once open these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi dose injectable vial and ophthalmic medication an item for which the manufacturer has specified a usable life after opening. The original seal of a manufacturers container or vial is initially broken the container or vial will be dated. The members shall place a date open sticker on the medication and enter the date open and the new date of expiration. The expiration date of the bio or container will be 30 days unless the manufacturer recommends a murder D or regulation/guidelines require different dating. The nurse will check the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145608 If continuation sheet Page 7 of 9 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 08/01/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete expiration date of each medication before administering. no expired medications will be administered to a resident. All expired medication will be removed from the active supply and destroyed in the facility regardless of amount remaining the medication will be destroyed in the usual manner. Disposal of any medication prior to the expiration dating will be required if contamination or decomposition is apparent. Nursing staff should consult the dispensing pharmacies for any questions related to medication expiration dates. Event ID: Facility ID: 145608 If continuation sheet Page 8 of 9 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 08/01/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review the facility failed to have an effective policy and practice for eliminating odors in the facility. This has the potential to affect all residents, staff, and visitors of the facility. On 7/29/25 during the survey tour, there were strong odors noted in the hallways and on the care unit three hundred.7/29/25 V13 (Facility Ombudsmen) said the odors in the facility has been an going issue.On 7/31/25 at 2:12pm V2 (DON/Director of Nurses) said the facility has contracted a company to clean the carpets, but the smell remains. 7/31/25 at 2:46pm V12 (Maintenance supervisor) said the odors are from the carpets. Things are spilled on the carpets, and residents have accidents sometimes. V12 said the carpets were cleaned by a service company 3 months ago. V12 said he uses the carpet extractor (Carpet Cleaner Machine) between having the carpet cleaned by a service company. V12 said the facility's carpet extractor is broken. V12 said the extractor has been broken for a while. Facility policy titled housekeeping services effective date January 2017 denotes in-part it is the policy of this policy to maintain a clean older free comfortable and orderly environment in all health care and public areas which meet the sanitation needs of the facility and resident rights were safe clean and comfortable like environment. The department shall routinely claim the environment of here to keep the facility free from offensive orders the accumulation of dust rubbish dirt and hazards. Event ID: Facility ID: 145608 If continuation sheet Page 9 of 9