Inspection·June 25, 2025

F 0584 Level of Harm - Potential for minimal harm Residents Affected - Many NUMBER]: 83.7F. Cardiac room [ROOM NUMBER]: 80.8F. Surveyor inquired about the current cardiac unit temperature V8 (Respiratory) stated For me I am okay, but I think it is too hot. Complex Hall: 81.4F. Complex room [ROOM NUMBER]: 81.6F. On 6/17/25 at 11:08am, V6 (Family) stated When you first come into the facility you don't feel any air. It's warm in the front of the building. On 6/17/25 at 11:26am, V3 stated The chiller is on now I (V3) got up there on the roof and made sure. It's 44 degrees for it to be operating properly. The city water temp is like 70 some degrees right now. It just started back up, it's probably like 72 degrees right now. It did get down to 69.2 before it shut off. Surveyor affirmed that the facility chiller was in fact running however it shut itself off during the inspection. On 6/17/25 at 2:01pm, V1 (Administrator) stated I (V1) got 3 portable AC (Air Conditioning) units so far and affirmed he was working on getting 15 more. On 6/17/25 at 3:00pm, V5 stated the HVAC (Heating Ventilation Air Conditioning) company arrived around 2:15pm and are checking the cooling system with a step-by-step diagnosis. We (facility) had 3 AC's that were delivered this morning; 2 are on cardiac (unit) and 1 is on joint (unit). On 6/17/25 at 3:09pm, surveyor toured the facility (again) with V5 (Maintenance), and the following atmospheric temperature concerns were noted: Joint Hall 84.3F. R6's (Joint) room temperature was 81.9F with a fan running. R6 stated It's hot so I had the window open just for ventilation because it's a slight breeze coming from outside. The Joint Activity Room was filled with residents, a blower and 2 large fans were running however the temperature was 83.2F. The residents participating in the Joint Activity Room were non-interviewable due to cognitive status per V5. North Dining room [ROOM NUMBER].8F. Cardiac Hall: 82.6F. Cardiac room [ROOM NUMBER]: 83.2F. Complex Hall: 83.7F. Complex room [ROOM NUMBER]: 83.8F with 2 fans running. On 6/17/25 at 3:29pm, surveyor inquired about the current facility temperature V12 (Certified Nursing Assistant/CNA) stated, It seems pretty cool right now, just a little bit of hot. On 6/17/25 at 3:31pm, V13 (Licensed Practical Nurse) stated, It was cool this morning, but it got a little warm this afternoon, so I turned some of the lights off. On 6/17/25 at 3:33pm, V14 (CNA) stated It's really really hot while standing at the Joint Unit nurse station. On 6/17/25 at 7:59pm, V1 affirmed the facility received (15) additional portable AC's that are up and running on all the units, aside from the ortho unit (which uses a different chiller). On 6/23/25 at 9:00am, the facility atmospheric temperature was notably warm/humid when surveyor entered the facility and the portable AC units were still in use. On 6/23/25 at 9:29am, surveyor inquired about the facility chiller V1 stated It was working this weekend but today it went out because of a heat sensor and affirmed that the HVAC company was called to repair the chiller today. On 6/23/25 at 2:34pm, V3 presented the (6/23/25) facility temperature logs which affirm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145211 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 145211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thryve of Burbank 5400 West 87th Street Burbank, IL 60459 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 0584 Level of Harm - Potential for minimal harm Residents Affected - Many temperatures (throughout the entire facility) were above 80F at 2:19pm (including ortho hall 81.7F). V3 affirmed the temperature on the ortho unit was likely elevated due to humidity coming from the other units. V3 stated When I (V3) got here this morning the chiller tripped and went out on low water flow because we (maintenance staff) had to clean it again. It ran for maybe 45 seconds, and it tripped again after that I made a call to (V1) to let him know we had an issue and contacted the HVAC company as well. The HVAC company arrived around 9:30 today, they hooked up a cleaning solution to clean out the heat exchanger. Around 1pm, that was completed but we had to fill the chiller up again with water which takes about 30-45 minutes because it's a big system. We (facility) now have 23 portable AC units running. On 6/23/25 at 3:11pm, V1 stated The chiller is up and running. The summer temperature monitoring guideline (revised 8/5/24) states routine temperature and humidity monitoring of the facility will occur at a minimum one time per day during daylight hours. The accommodation of needs and homelike environment guideline (revised 10/2023) states the resident's environment will be maintained in a homelike manner to ensure comfortable and safe temperatures. Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to risk of hyperthermia and is comfortable for the residents. A determination of homelike should include the resident's opinion of the living environment. The extreme temperature guidelines (revised 4/3/24) states should the temperature index for relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145211 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 145211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thryve of Burbank 5400 West 87th Street Burbank, IL 60459 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to maintain the chiller (air conditioner), failed to clean intake vents, failed to document equipment maintenance, and failed to ensure that the chiller was functioning properly. These failures affected 108 residents residing in the facility. Residents Affected - Many Findings include: The (6/17/25) census includes 108 residents. On 6/17/25 at 9:21am, V3 (Maintenance Director) stated right now I'm (V3) having an issue with the chiller, which is brand new, it was installed last year. There's dirt and debris in there so I (V3) was up on the roof trying to flush it out. When there's dirt that builds up, it will throw a low water flow diagnosis so basically if the waters not at a certain flow it will throw that code and shut the unit down. Surveyor inquired if the chiller was currently shut down. V3 replied Right now yes because I was cleaning it. On 6/17/25 at 10:48am, V5 (Maintenance) stated The chiller is having low water flow pressure today so (V3) is working on it as we speak. The system is new it was put in last year, the problem is putting the flow of water back in order. The water goes through a filter, but material goes through the filter and slows up the water, sometimes it will shut the system off if it fills up that filter. It did kick off maybe sometime this morning. On 6/17/25 at 11:26am, V3 stated The chiller is on now I (V3) got up there on the roof and made sure. It's 44 degrees for it to be operating properly. The city water temp is like 70 some degrees right now. It just started back up, it's probably like 72 degrees right now. It did get down to 69.2 before it shut off. Surveyor affirmed that the facility chiller was in fact running however it shut itself off during the inspection. V3 responded I'm gonna shut it off and release the valve again. V3 opened the chiller valve and released the water which was notably brownish-black. V10 (Regional Maintenance Director of Operations) stated See the black stuff? We may have to do this like 3 or 4 times and were gonna clean the strainer. This one should be fine after we clean the strainer. The chiller strainer was soiled with rust colored debris therefore sprayed with water repeatedly. V10 responded Were gonna have to strain this at least 4 or 5 times until it comes out clear, there's a lot of [NAME] in there so we may have to flush it again. We're not gonna leave till it's fixed. Surveyor inquired about the facility intake vents which were completely covered in dust, debris, and cottonwood remnants. V10 inspected the vents and replied, This is dirty, we gotta clean that one too. At 11:57am, the chiller was restarted. V3 stated it's 73.3 degrees that's coming in and 60.2 is actually what's flowing through the building. Once everything gets to flowing good this 73 degrees will drop down even more, we're at 71 degrees now. While V3 and surveyor were checking the numbers the chiller shut off (again). V11 (Regional Maintenance) stated It shut down the pump. V10 responded We should do that bottom one too however the maintenance staff were unable to remove the bottom plate therefore had to purchase additional items to do so. V10 affirmed We started a pre-maintenance program a few months ago to prevent things like this happening. There's a screen that filters the water which will shut down the unit. The heating and cooling guy is coming, we (facility) need a little bit of freon somewhere else too. At 12:54pm, the chiller was restarted (again) V11 stated We got pressure, right now we got 40. It didn't go to 40 last time. V3 and surveyor affirmed that the chiller circuit 1 and circuit 2 were running the water temp was 70.1 and incoming water was 55.3 at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145211 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 145211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thryve of Burbank 5400 West 87th Street Burbank, IL 60459 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The (6/17/25) facility HVAC (Heating Ventilation Air Conditioning) invoices states the chilled water is extremely dirty and chiller bundle has flow restrictions. Cleaned the strainers multiple times once the system was filled, bled, and pump was running. Will quote to clean system up, replace chemical filters and further clean system. On 6/23/25 at 9:29am, portable AC units were still in use at the facility however the temperature was above 80F/Fahrenheit throughout the building (per 6/23/25 temperature logs). Surveyor inquired about the facility chiller V1 stated It was working this weekend but today it went out because of a heat sensor. The (6/23/25) facility HVAC invoice states the system locked out on low flow. Shut down pump, isolated chiller, and cleaned strainer. Removed and replaced white cylinder filters. Restarted chiller. Low flow alarm is nearly immediate. We will isolate the chiller, drain down the heat exchanger and flush with chemical. On 6/23/25 at 3:11pm, V1 affirmed The chiller is up and running. On 6/24/25 at 10:48am, surveyor inquired about the facility chiller maintenance. V5 stated We (Maintenance) change filters and we add chemicals to treat the water that's the regular maintenance that's supposed to be done for that. We're changing the filters weekly, and I think its monthly for the chemicals. On 6/24/25 at 11:27am, surveyor inquired about the facility chiller maintenance. V3 stated Weekly I (V3) change the 4 small filters and monthly add (2) 5 gallons of cleaner. Surveyor requested documentation for the chiller maintenance. V3 responded I don't have any records for that, I'll be honest with you I just don't. The (February 2014) preventive maintenance policy states the preventive maintenance program is maintained by the maintenance department. The maintenance department checks for preventative maintenance program equipment work orders and evaluates/repairs the malfunction described. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145211 If continuation sheet Page 5 of 5