Thryve of South Holland

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an environment free of accidental hazards, failed to provide an appropriate level of supervision, and failed to ensure the availability and use of an assistive device required for safe mobility for one (R1) of four residents reviewed for falls in a sample of four. This failure resulted in R1 sustaining a fractured hip, which required hospitalization and surgical intervention.

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that the Minimum data set (MDS) assessment was recorded with accurate information for 5 of 5 residents (R1, R14, R45, R113 and R18) reviewed for accuracy of MDS.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedure for fall prevention by not ensuring the fall intervention of providing two-person assistance for transfers was implemented while providing care for a resident who is totally dependent on staff for transfers. This failure applies to one of four residents (R3) reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow two residents fall care plan and failed to transfer two residents (R1, R2) in a safe manner using a wheelchair and mechanical lift in a sample of three. These failures resulted in R1 sustaining an avoidable fall out of wheelchair and R2 sustaining a fall while using a mechanical lift resulting in R2 being sent to hospital due to constant headache, left hip, left elbow and left leg pain for three days.

Inspectors wroteBased on interview and record review the facility failed to report to state agency two unusual occurrences for two (R1, R2) of three residents reviewed for incidents and accidents. This failure resulted in R1 and R2 sustaining avoidable falls and R2 being sent to hospital with constant headache, left hip pain, left elbow pain and left leg pain.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate assistance with activities of daily living. This failure applies to five of five residents (R1, R2, R3, R4, and R7) reviewed for ADL's (Activities of Daily Living).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide assistance for residents assessed to need assistance with activities of daily living and failed to provide assistance and/or supervision with feeding. These failures applied to three of three residents (R1, R3, and R4) reviewed for activities of daily living.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for catheter care by not ensuring residents catheters were positioned properly to prevent contamination. This failure applies to two of three residents (R1 and R5) reviewed for catheter care.

Inspectors wroteBased 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. 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). [...]

Inspectors wroteBased on interview and record review the facility failed to follow their practice and ensure to transcribe a physician order to include the right dose, right diagnosis, and duration for prednisone 60mg (milligram) tablets, and failed to complete an order for Norco 7.5mg-325mg for 3 days for one of one resident (R1) reviewed for physician orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (activity of daily living) care to a dependent resident and provide incontinence care at least every two hours, and failed to ensure residents are provided a bath per facility policy. This affected four of four residents (R1, R3, R4, and R6) reviewed for activity of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision during smoking breaks for a resident (R8) identified to require supervision. This affected one of three residents (R8) reviewed for safety during smoking.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident call light is within reach. This deficiency affects one (R44) of three residents in the sample for 26 reviewed for Accommodation of needs and Resident safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to post information including names, address (mailing and email) and telephone numbers of the State Long Term Care (LTC) Ombudsman Program in a form and manner thats accessible and understandable to residents and resident's representatives. This deficiency affects one (R116) of three residents in the sample of 26 reviewed for Resident rights.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R111) from verbal abuse by a staff member. This deficiency affects 1 (R111) of 4 residents in a sample of 26 reviewed for abuse prevention.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan that meets resident's choice of activities and Activities of Daily Living (ADL). This deficiency affects one (R116) of three residents in the sample of 26 reviewed for developing comprehensive care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive necessary services to maintain good grooming and personal hygiene. This deficiency affects two (R44 and R116) of three residents in the sample of 26 reviewed for ADL (Activity of Daily Living) care services.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy on prevention of pressure ulcer's by failing to ensure low air loss mattress is properly functioning and failing to apply bilateral heel protector's when in bed as ordered by physician. This deficiency affects two (R44 and R91) of three residents in the sample of 26 reviewed for Pressure ulcer prevention program.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foot care and preventive treatment to a diabetic resident to prevent podiatric complications. This deficiency affects one (R44) of three residents in the sample of 26 reviewed for Diabetic Foot care services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pain was assessed before and during wound care, for 1 of 3 residents (R65) in a sample of 26 reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure daily refrigerator temperature check inside the resident room to ensure proper temperature and food safety. This deficiency affects two (R29 and R128) of 2 residents in the sample of 26 reviewed for Resident safe food storage.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their housekeeping policy and procedures by not ensuring the memory care unit was clean and free of odors. This failure applied to all 21 residents currently located in the memory care unit.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for notice of change in condition by not ensuring resident's family members were notified of changes in resident health status and medications. This failure applied to three of four residents (R4, R5, and R7) reviewed for notice of change.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that a resident received physical therapy services for which the resident was assessed and care planned for, with physician orders in place. This failure applied to one of one resident (R4) reviewed for physical therapy services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on resident's rights by failing to knock on the door before entering a resident's room for 4 of 8 residents (R107, R125, R236, R237) in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care to a dependent resident. This deficiency affects one (R185) of three residents in the sample of 28 reviewed for providing Activity of Daily Living (ADL) Care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer recommendation in using low air loss mattress to a resident who has multiple unstageable pressure ulcers. This deficiency affects one (R185) of three residents in the sample of 28 reviewed for pressure ulcer prevention management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to monitor resident for one of one resident (R51) in the sample of 28 reviewed for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician order for medical indication and size for using indwelling catheter to a resident. This deficiency affects one (R185) of three residents in the sample of 28 reviewed for Urinary Catheter Management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label ongoing tube feeding for one of two residents (R36) reviewed for tube feeding in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' refrigerator for three of three residents (R41, R51, R44) observed for food safety in a sample of 28.