Health inspection·July 30, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hydrocephalus), diabetes mellitus type 2, adjustment disorder and anxiety, dorsalgia, unspecified pain, anxiety, syncope, collapse, ataxia, obstructive sleep apnea, age related debility, convulsions, altered mental status, anemia, and age related osteoporosis without current pathological fracture. The Physician Order Sheet (POS) and EMAR (Electronic Medical Administration Record) for the month of April and May of 2023 shows R1 was prescribed and administered Keppra 500 mg twice a day and Vimpat 100 mg twice a day (scheduled for administration daily at 9:00 A.M. and 9:00 P.M., antiseizure medications) while R1 was at the facility from 4/22/2023 to 5/21/2023 (for the 9:00 A.M. dose). On 4/30/2023 at 9:01 P.M., R1 was prescribed Mirtazapine 15 mg. for anxiety to be given daily every 6:00 P.M. The EMAR for the month of May 2023 shows that on 5/1 and 2 of 2023, R1 was administered with Mirtazapine 15 mg. at 6:00 P.M. (total of two 2 doses/two days). On 7/28/2023 at 9:12 A.M., V10 said, I was not informed regarding the Mirtazapine and only found out later when it was already given to him (R1) 2 days later. I did not consent for this drug to be administered because it can add sedation and I know he (R1) is declining, not the same anymore. The Electronic Consent; Psychoactive Medications: dated 5/1/2023 shows on 5/1/2023 at 00:00 hours V3 (RN/ADON) filled out the Signature Consent Form for a consent for the use of Mirtazapine ordered for R1. This form required a signature from V10 (R1's wife/POA (Power of Attorney). This form had no signature from V10 to show she consented the use of the Mirtazapine. On 7/28/2023 at 11:15 A.M., V3 had explained there was no signature, since it was electronic and a Antipsychotic/Psychotropic Informed Consent in a hard copy must be used and scan for electronic record. V3 said there was no consent to show V10 had sign the consent for use of Mirtazapine medication. V3 also said on 5/3/2023, V10 was upset because the Mirtazapine was administered to R1 without V10's approval. V3 added V10 said to hold the medication until she talked to the prescribing nurse practitioner from psychiatry. The facility's policy, dated 5/2023, for Psychotropic Medications shows all psychotropic medication order will be initiated by the facility only after the Informed Consent was completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 2 of 5 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 146192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lisle 2850 Ogden Avenue Lisle, IL 60532 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly assess and monitor a resident with a significant decline in condition. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for change in condition. The findings include: The EHR (Electronic Health Record) shows R1 was [AGE] year-old that had been from 2 previous nursing homes and multiple hospitalizations before admission to the facility. R1 was previously staying at his home, had falls and weakness, then was hospitalized from 4/3-10/2023. R1 was sent to the first nursing facility for deconditioning on 4/10/2023-4/15/2023. R1 was at the second nursing facility up to 4/16/2023 (one day), then was sent out to the hospital for management of right hip fracture and treatment for seizures. Neurology was consulted, and R1 was placed on two antiseizure medications (Keppra and Vimpat). During this hospitalization, R1 was evaluated for a possible acute CVA (cerebral vascular accident). There was diagnostic imaging (MRI/Magnetic Imaging Resonance) done, and it showed acute punctuate hemorrhages, so R1 was started on Aspirin management. The Hospital Discharge Form, dated 4/21/2023, which was provided to the facility as a referral communication shows R1's history as follows: -R1 has had recent hospitalization for weakness, fell at home while trying to get up from wheelchair. History of admission for generalized confusion with no acute, reversible cause. It also shows dementia with deconditioning as cause for falls/confusion/generalized weakness. The record also shows R1 was positive for UTI (urinary tract infection) which this may be etiology of (R1's) acute worsening. The hospital record referral also shows recommend neuropsychiatry testing on discharge - referral given to patient/wife on discharge last admission. He is 2 months post insertion of a programmable ventriculo-peritoneal (VP) shunt for possible normal pressure hydrocephalus. I agree with Dr that his current decline likely represents the effect of the UTI superimposed on underlying dementia. Unfortunately, the patients lack response to CSF drainage indicates that his Dementia is not primarily due to NPH (Normal Pressure Hydrocephalus). The record also shows R1 was admitted to the facility on [DATE], after a hospitalization from 4/16-22/2023. R1 had undergone recent right hip hemiarthroplasty on 4/17/2023 due to right hip fracture that was identified on 4/16/2023. On 4/17/2023, R1 was noted with a new witnessed seizure 4/17/2023, neurology consulted, and was initiated with two antiseizure medications (Keppra and Vimpat). R1, while at the hospital, was also identified with possible acute CVA, acute on chronic AMS (altered mental status), falls, VP shunt placed 2/2023, progressive dementia, a 3.8 mm left basilar aneurysm, dementia, and delirium. The hospital record also shows documentation a physician had documented I fear patient will not make meaningful improvements, it seems his dementia was rather advanced even prior to VPS placement- (V10, R1's wife) endorses (R1's) many years of drinking & smoking. She understands prognosis and would be very open to hospice/palliative care discussions. The hospital record, dated 4/17/2023, shows Internal Medicine, (R1) agitated overnight, given morphine & Seroquel earlier for pain/agitation. Not following commands at baseline. The EHR showed R1's other diagnoses included but not limited to NPH (Normal Pressure Hydrocephalus), diabetes mellitus type 2, adjustment disorder and anxiety, dorsalgia, unspecified pain, anxiety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 3 of 5 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 146192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lisle 2850 Ogden Avenue Lisle, IL 60532 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few syncope, collapse, ataxia, obstructive sleep apnea, age related debility, convulsions, altered mental status, anemia, and age related osteoporosis without current pathological fracture. On 7/28/2023 at 9:12 A.M., V10 (R1's wife) said, (R1) was not definitely the same and was physically and mentally declined. The day before he was sent out 5/21/2023, I saw him during the day around lunch, he was sitting in his wheelchair in the dining room, and he was not eating. (V6) (CNA/Certified Nurse Assistant) had told me he noticed (R1's) was not the same from his baseline, something different and significant because (R1) was barely responsive and did not eat at all during the day. I was told it had worsened during dinner time and (R1) was just left in bed because of increased lethargy and barely responsive. They should have sent him to the hospital. It was the next day he was sent out (5/22/2023). In the ER Hospital, the doctor pinches (R1) and he did not response. The doctor told me (R1) has a brain bleed but did not tell me the caused and I did not ask either. I was told it was an inoperable brain bleed. (R1) was at the hospital from 5/22-24/2023 then to hospice center from 5/24-6/5/2023. (R1) passed away 6/5/2023. The death certificate shows R1 had passed away on 6/5/2023 and the immediate cause of death was non-traumatic intracerebral hemorrhage. Review of the progress notes on 5/21/2023 shows no documentation throughout the day and night about R1's condition. There was no entry until the morning of 5/22/2023 at 8:40 A.M when V11 (RN-Registered Nurse) documented, (R1) received in room comfortably sleeping but appears with change in condition, (R1) is more lethargic but responsive . Later, V11 charted on 5/22/2023 at 9:40 A.M: (R1) remain alert but slow to respond to care, unable to eat breakfast or take medication, NP informed about res (resident) condition. Later at 12:01 P.M, the EMR notes R1 was sent to the local hospital for further evaluation due to slow response to care. -5/23/2023 at 4:28 P.M.: Call to hospital, (R1) in ICU (Intensive Care Unit, no dx (diagnosis). On 7/28/2023 at 2:10 P.M., V6 (CNA assigned to R1 on 5/5/21/2023 for day and evening shift) said on 5/21/2023 during the day and evening shift, R1 was noted with a significant change. V6 said it was already lunch time when R1 was assisted out of bed because R1 was extremely weak, barely responsive. V6 added R1 did not eat lunch or dinner, and R1 was not able to swallow his food. V6 also stated R1 was barely awake and did not respond. V6 said he informed the nurse either V12 (RN) or V4 (LPN) when he had notice R1's significant change with increased weakness, lethargy and was not eating. V6 said definitely R1 was not at his baseline. On 7/28/2023 at 3:12 P.M., V4 (LPN/License Practical Nurse, assigned to R1 on 5/21/2023 for day and evening shift) said V6 had notified her of R1's significant change in mental and physical condition on 5/21/2023 around lunch time. V4 said she also noticed the change sometime in the morning, of R1 being extremely weak and lethargic and barely responsive. V4 said for lunch time, R1 was assisted to wheelchair, but did not swallow his food, only a crushed medicine. V4 said it took a long time before R1 was able to swallow a small amount of crushed medication. V4 said as day progressed to evening, R1 also worsened in condition and was more lethargic and weaker. V4 said R1 just stayed in bed all evening and did not eat dinner. V4 added, I think I did assessment called the wife and she said wait till tomorrow. V4 also admitted this was not documented in R1's medical record. On 7/28/2023 at 12:58 P.M., V8 (Nurse Practitioner of V9) said staff should have done a thorough assessment to determine neurological function such as checking for pupils if they were equal and reactive to light, checking upper extremities if they are even in strength and not drifting away or can hold balance, facial asymmetry, responsiveness verbal and tactile stimuli, and slurred speech. V8 said these are few examples of neurological assessment and should have been done and physician must be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146192 If continuation sheet Page 4 of 5 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 146192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lisle 2850 Ogden Avenue Lisle, IL 60532 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notified promptly to determine correct treatment such as sending R1 to hospital for further evaluation and treatment. On 7/29/2023 at 4:08 P.M., V9 (R1's Attending Physician) said he saw R1 on multiple times on May 9,12 and 16 of 2023). V9 said R1 was 'neurologically stable. V9 also said, However, if there was a significant change the day before he was sent out on 5/22/2023, then facility should have called the on-call physician to provide orders for further treatment and send (R1) to the hospital for further evaluation and treatment. Surveyor informed V9 of R1's immediate cause of death as specified on R1's death certificate. V9 responded, Non-traumatic intracranial hemorrhage could happen abruptly, and symptoms was undetectable before the bleeding sets in, that how fast it sets in. It is unknown and I cannot tell for sure the cause, but he was a sick man with multiple comorbidities with stroke in the most recent hospitalization and also had aneurysm. Event ID: Facility ID: 146192 If continuation sheet Page 5 of 5