Health inspection·October 21, 2024

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 Based on interview and record review, the facility failed to immediately transport one resident with an acute change in medical condition. This affected one of three residents (R1) reviewed for change in condition. Residents Affected - Few Findings include: On 10/19/24 at 11:20 AM, V5 (Nurse) stated that the nurse is responsible for obtaining the resident's vital signs. V5 stated that if there is a change in the resident's condition, the nurse calls the physician and sees what he wants to do. V5 stated that if the physician is unavailable then the nurse is expected to contact V2 DON (Director of Nursing) for further instruction; if unavailable calls V4 ADON (Assistant Director of Nursing). V5 stated that if V4 is unavailable, the nurse calls the supervisor. V5 stated that if unable to reach anyone, then calls EMS (Emergency Medical Services) 911 to transport the resident to the hospital. V5 stated that if the resident is not stable, including but not limited to, abnormal vital signs, new onset seizure, V5 would call EMS 911 immediately prior to attempting to contact physician. On 10/21/24 at 11:54 AM, V7 (Nurse) stated that 8/15/24 was the first time V7 provided care for R1. V7 stated that R1 appeared to look okay when V7 rounded on him in the morning. V7 stated that when V7 rounded on R1 in the afternoon, R1 appeared to be warm and shivering; not how he appeared earlier that day. V7 stated that V7 asked other staff how R1 was normally and was informed this was not his baseline. V7 stated that V7 sent a communication to V9 NP (Nurse Practitioner) regarding R1's change in condition. V7 stated that R1's blood pressure was low and heart rate slightly elevated at 103 beats/minute. V7 stated that V7 requested an order to administer intravenous fluids for R1's low blood pressure. V7 stated that V9 did not want to administer fluids due to possible fluid overload. V7 stated that R1's oxygen saturation level was 90% on room air so she applied oxygen at 3 liters per nasal cannula. V7 stated that V9 ordered antibiotic medication to be given intramuscularly. V7 stated that R1's oxygen level would not improve on the oxygen and R1 did not appear stable. V7 stated that she does not recall if R1 was sent to the hospital via EMS 911 or by outside ambulance company. On 10/21/24 at 1:13 PM, V9 NP (Nurse Practitioner) stated that V9 was not aware that R1's potassium level on 8/9/24 was 2.8 (normal range 3.6 - 5). V9 stated that V9 was present at this facility on 8/15/24 in the afternoon for routine rounding on residents. V9 stated that when V9 arrived on R1's nursing unit, V9 was informed to check on R1 because he did not look good. V9 stated that V9 assessed R1 and ordered urgent laboratory testing to be done. V9 stated that R1 is normally alert and communicative. V9 stated that R1's oxygen saturation level was 90% so V9 applied oxygen at 3 liters per nasal cannula. V9 stated that V9 did not send R1 to the hospital via EMS 911 because R1 was stable after V9 applied oxygen. V9 stated that R1's oxygen level improved to 95% or higher and remained stable until transported to hospital. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145718 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 10/21/2024 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)