Health inspection·September 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few altercation and were immediately separated. R4 was placed on observation and sent to the hospital for an evaluation. First aid was rendered to R5. R4 stated that R5 bumped into R4's wheelchair with R5's wheelchair while getting on the elevator which made R4 angry. R5 stated that R5 accidentally bumped into R4's wheelchair entering the elevator and R4 became physical towards R5. On 9/17/24 at 12:02PM, R5 admitted to getting into a physical altercation with R4. R5 reported R5 was trying to get onto the elevator while R4 was on the elevator first. R5 stated R5 asked R4 move up due to not having enough room to fit both of their wheelchairs on the elevator. R5 denied R4 responding, so R5 inched up closer to get all the way onto the elevator, so the door could close. R5 reported R5's wheel bumped into R4's wheelchair. R5 stated R4 immediately turned R4's wheelchair around, stood up and begin hitting R5 in the face and hand with R4's closed fist and cell phone. R5 stated R4 hit R5's hand with the cell phone causing pain to the ring finger. R5 reported having a scratch to the face and pain to the finger but denied any serious injuries. On 9/17/24 at 3:22PM, V9 (Nurse) stated R4 was on the elevator facing the rear in a wheelchair and R5 was trying to get on in a wheelchair. V9 reported R5 asked R4 to move up a little bit so R5 could have some room. V5 stated R4 said R4 couldn't move any more. V9 reported R5 tried to inch up a little bit more so the elevator door would close. V9 reported R4 turned around R4's wheelchair and then stood up and started hitting R5. V9 stated R4 hit R5 in the face a couple times and then was punching R5 in the hand with R4's cell phone. V9 reported staff jumped up and told R4 to stop hitting R5. V9 stated both residents were removed from the elevator and R5 had a scratch on R5's face from where R4 hit R5. V9 reported R5 also said R5's finger hurt. V9 stated this incident would be considered physical abuse. On 9/19/24 at 3:08PM, V14 (CNA) stated V14 was on the second floor when the elevator door opened. V14 reported R4 was already in the elevator and R5 went to go get on. V14 stated they both were in wheelchairs and R5 asked R4 to move up a little bit. V14 stated that set R4 off and R4 stood up and started hitting R5 with R4's fist and a phone. V14 reported staff all ran up to stop R4 from hitting R5. V14 stated R5 had a little mark on R5's face, but that was it. V14 reported the only thing R5 did was ask R4 to move up and R4 immediately got upset. V14 stated this would be considered physical abuse because R4 hit R5. V14 denied R5 hitting R4 back. On 9/20/24 at 11:36AM, V15 (DON) stated V15 was not present for the incident but was told both residents were trying to fit on the elevator. V15 reported R5 accidentally hit R4's wheelchair with R5's wheelchair and R4 got upset with R5. V15 stated R4 then began swinging and hitting on R5 with R4's fists and cell phone. V15 reported this would be considered physical abuse. The Care Plan dated 6/7/21 documents R4 is at risk for alteration and sensory perception related to a diagnosis of schizophrenia, being at risk for inappropriate responses, misinterpretation of environments, or inappropriate response to environment. The Care Plan dated 8/27/24 documents R4 displays physical behavioral symptoms directed towards others. R4 has been verbally and physically aggressive towards others. Appropriate interventions are documented. The Minimum Data Set for R4 dated 8/27/24 documents a Brief Interview for Mental Status score as 15 (cognitively intact). The Aggression Risk Review dated 8/27/24 documents R4 displayed physical and verbal aggression. R4 is verbally aggressive towards staff. R4 was involved in an altercation with a resident. R4 was referred for a psych evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 2 of 3 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 145718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thryve of Crestwood 14255 South Cicero Avenue Crestwood, IL 60445 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Care Plan dated 7/1/24 documents R5 is at risk for abuse due to being in a skilled facility. On 8/27/24, R5 was involved in a physical confrontation with a peer. Interventions include: assess for risk for abuse quarterly and as needed, observe for signs and symptoms of abuse, and report all instances of abuse to the abuse coordinator. The Minimum Data Set for R5 dated 8/14/24 documents a Brief Interview for Mental Status score as 15 (cognitively intact). The Abuse Risk Review dated 5/14/24 documents R5 is at risk for abuse related to R5 residing in a skilled nursing facility. R5 has not made any allegations of abuse. R5 currently has no other risk factors. The Abuse Risk Review dated 8/27/24 documents R5 has experienced abuse and has made an allegation since the last review. The policy titled, Abuse Prevention Policy, that is undated documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and treatment of residents . Abuse: Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental to a resident .Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 3 of 3