Thryve of South Holland

In the surveyor’s words

From the most serious findings on record at Thryve of South Holland, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 4, 2026

  Based 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.Findings include:R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Unspecified Severity with other Behavioral Disturbance; Anemia; Peripheral Vascular Disease; Essential (Primary) Hypertension; Abnormalities of Gait and Mobility; Anxiety Disorder;… […]

• Actual harm, isolatedF686Aug 1, 2025

  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: R32's Braden scale for predicting pressure sore risk dated 6/26/25 documents: high risk. […]

• Actual harm, isolatedF689Jun 23, 2025

  Based 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. Findings include: R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia cervical 1-cervical 4 complete, anxiety disorder and spinal stenosis cervical. […]

• Actual harm, isolatedF686May 23, 2023

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcer/pressure injury (PU/PI) development for residents who were admitted without PU/PIs and totally dependent on staff for care and assessed to be at increased risk for PU/PI development; the facility also failed to provide ongoing skin assessments for these residents. This failure affected three (R4, R5 and R7) of four residents reviewed for pressure ulcers and resulted in R4 developing a stage 4 facility acquired wound to the right buttock, R5 developed a stage 3 facility acquired wound to the coccyx, and R7 developed a stage 3 facility acquired wound to the sacrum. […]

• Actual harm, isolatedF689Feb 18, 2023

  Based on observation, interview, and record review, the facility failed to provide supervision and assistance for a resident assessed to require assistance with toileting. This failure applied to one (R3) of one resident reviewed for accidents and supervision and resulted in R3 having a laceration to her back and being sent to local hospital for evaluation and treatment. Findings include: R3 is an [AGE] year-old-female who was admitted to the facility on [DATE] for skilled nursing/24 hours observation, with past medical history of Nontraumatic subarachnoid hemorrhage unspecified, insomnia, anxiety disorder, weakness, difficulty walking, chronic kidney disease stage 3, history of falling, primary pulmonary hypertension, etc. […]