Health inspection·January 31, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Thursday. R1 reported attempting to take a shower on Monday and Wednesday this past week due to missing the scheduled shower days but the showers were still cold on Monday and Wednesday as well. R1 stated R1 has been washing up with provided wipes or with water that is warmed in the microwave by staff. R1 reported asking CNAs and nurses why the water was cold and staff told R1 that maintenance was aware. R1 stated R1 was unaware what maintenance was doing for the problem and no updates have been provided on when the showers will be properly functioning again. R1 reported R1 has been able to wash up but still feels dirty by not being able to take a full shower. On 1/7/25 at 1:52PM, V3 (Nurse) stated V3 was notified as on today that the showers are giving out hot water. V3 reported management has told staff to hold off on giving showers until the temperatures are back within normal range. V3 stated some residents are upset at not being able to shower and only given wipes or a bucket of warm water to wash up. On 1/7/25 at 2:19PM, R4 stated the water has been cold in the facility. R4 reported R4 takes both a shower and a bed bath. R4 stated both the shower and bed bath water have been cold. R4 reported the water has been cold for about one week. R4 denied being told by management when the hot water would be fixed. On 1/7/25 at 2:25PM, V5 (CNA) stated the facility has not had hot water in the showers for about one week and residents who normally take a shower have not had the opportunity to shower for that time now. V5 reported the CNAs are bathing people with wipes or warm water after microwaving it. V5 denied knowing when this issue would be fixed. V5 stated maintenance and management were made aware of the issue as soon as staff knew about the cold water about a week ago. On 1/7/25 at 2:28PM, V6 (CNA) stated V6 last time the showers were functioning properly was on Christmas when V6 worked. V6 reported V6 was next at work and the showers only had cold water. V6 stated residents went to take a shower this day and told staff the water was too cold to shower. V6 was not aware when maintenance was notified of the issue and was also not aware when the issue will be fixed so residents can shower again. V6 stated V^ touched the water and it was really cold to the point where no one would be able to shower. On 1/7/25 at 2:38PM, R5 stated R5 was aware a company was in the building today working on the hot water. R5 reported being told this information by another resident. R5 denied being given any updates by the management at the facility. R5 reported R5 was admitted to the facility within the last 3 week and the shower have not had hot water since 12/30/24. R5 stated the facility has been giving the residents wipes to clean themselves with until the hot water is functioning again. R5 denied being given any updates on when the hot water will be working again. On 1/7/25 at 2:42PM, V8 (CNA) stated R1 normally showers independently. V8 was not able to remember the date but was told by management last week to postpone showers because they only were giving out cold water. V8 was not given any updates on when the showers would be fixed. V8 stated showers showers started giving out cold water for about a week but V8 does not know when maintenance was made aware. On 1/7/25 at 2:49PM, R6 stated R6 has not been able to take a shower since 12/29/24 due to the facility not having any hot water in the showers. R6 reported a CNA that was unable to be named told R6 on 12/31 that R6 would not be able to shower that day due to no hot water. R6 stated that R6 always takes a shower but has had to just wash up with a bucket of water and soap. R6 reported R6 needs to take a full shower instead of washing up with the bucket of water in order to feel clean. R6 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 2 of 14 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 01/31/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R6 feels like the facility is moving very slow in fixing the hot water issue and has not updated the residents on when the issue will be resolved. On 1/7/25 at 2:57PM, V1 (Assistant Administrator) stated V1 was notified of the showers not having hot water on 1/4/25. V1 reported the plumbing company was called out on Friday (1/3/25) to clean the heat exchanger and told the facility 1/4/25 that the part would need to be replaced. V1 was not aware how cold the water temperatures in the shower were but was aware they were below 100 degrees F. On 1/7/25 at 3:50PM, V2 took the surveyor into the boiler room. The thermometer on the hot water tank was 151 degrees Fahrenheit (F). V2 reported this water comers in from the reservoir tank and that tank stays at 115 degrees F. V2 stated the water from the hot water tanks comes out of that tank and mixes with the reservoir tank and goes out into the pipes up to the floors at 128 degrees F. V2 reported the plumbing company took off the heat exchanger and cleaned all the sediment out of the part then replaced new copper piping which was completed at 3:20PM so the cold water is not fully cleared out of the tanks yet. V2 then took V1 (Assistant Administrator) and the surveyor to the floors to take water temperatures. At 3:53PM, room [ROOM NUMBER] sink was tested by V2 and was 104 degrees F. V2 then turned on the water of the third floor north shower room at 3:55PM. V2 let the water run until 4:01PM and then took the temperature. The temperature of the shower water was 55 degrees F. At 4:03PM, room [ROOM NUMBER] sink was 108 degrees F and the shower in this room was 74 degrees F. V2 then turned on the water of the fourth floor north shower room at 4:05PM. The temperature of the water in this shower room at 4:06PM was 68 degrees F. V2 then stated the water in the shower rooms on the second floor would be a suboptimal temperature as well due to the pipes still having cold water in them from earlier in the day. V2 reported it would take two to three hours for the water to be running within range again. On 1/7/25 at 4:21PM, V9 (Site Manager) stated V9 was notified 1/6/25 that the boiler was not properly functioning due to temperatures of the water dropping that were too cold for residents. V9 reported V9 talked to the contractor immediately and the contractors began ordering the part needed to repair the boiler. V9 said, I have no idea why I was notified yesterday. I don't know why I was not told about it sooner. On 1/9/25 at 9:45AM, V2 stated from 1/3/25 to 1/7/25 the plumbing company progressively tried different methods to get the water temperatures within range, but it ultimately took until 1/7/25 for optimal temperatures to be maintained. V2 reported the heat exchange part that needs to be replaced is still in route to the facility and will be put on as soon as it arrives. V2 stated water temperatures were taken every two hours while V2 was in the facility but V2 only documented the temperatures once a day. On 1/9/25 at 1:53PM, R3 stated the hot water was working again on Tuesday night around 8PM. R3 reported R3 took a shower last on 12/29/24. R3 stated that the facility provided wipes to wash up. R3 reported R3 only feels clean after taking a shower versus using the wipes. R3 denied being kept up to date with what was going on with the hot water. R3 denied any issues with the hot water since it was back within normal range again on Tuesday night. The Service Request dated 1/3/25 documents a service was requested for the water heaters in the mechanical boiler room due to no hot water. The heat exchange coil is malfunctioning and needs immediate attention. This request was created at 9:38 AM. A technician arrived to the facility at 12:05 PM. The technician departed the facility at 5:59 PM, but the work for this job was not yet completed. The issue is temporarily fixed and a quote is needed. The technician suggested the unit will need a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 3 of 14 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 01/31/2025 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 0584 new heat exchanger at the minimum to be operational. Level of Harm - Minimal harm or potential for actual harm There is no documentation that the plumbing company was in the facility on 1/4/25. Residents Affected - Some The Service Request dated 1/5/25 documents the plumbing company was called out to the facility at 11:10 AM. The technician arrived and completed services from 12:26 PM to 3:05 PM. It is documented that the servicing cost is not to exceed $6750 per the facility's documented not to exceed limit. The technician documented the work for the facility is not yet completed because the not to exceed limit has not been adjusted or approved. No work can be completed without a higher estimate for the job being given to the plumbing company. The plumbing manager spoke with the facility corporate regarding this repair and will follow up. The boiler plate has cracks and needs to be welded, and additional repairs may be needed after [NAME] process is started as the overall condition of the steel is unknown. If additional work is required, the not to exceed limit needs to be increased and submitted for approval. The Project Proposal dated 1/4/25 was created on this day and a pending service quote is needed. On 1/7/25 at 10:04 AM the quote is still pending approval. At 11:32 AM, the quote was accepted and authorized by V9. The Finalized Proposal dated 1/7/25 documents the maintenance director requested service for the water heaters and upon inspection, the technician determine that at a minimum, the unit requires a new heat exchanger to become operational. Work is expected to start on site within the next 2 to 10 days following approval of the proposal and availability of the part. A heat exchanger was ordered on this day. The total cost of the materials, labor, and expedited shipping cost $24,794. The Water Temperature Log from 12/13/24 through 1/6/25 document temperature ranges from 101°F through 110°F. There was no documentation of water temperatures being taken when the dipping temperature occurred. On 1/3/25 at 9 AM, shower temperatures were documented at 101°F. On 1/4/25 at 5:30 PM room [ROOM NUMBER] was documented at 101°F. A comment on this day is documented as temperatures returned. On 1/5/25 at 11 AM, showers were documented at 101°F. On 1/6/25 at 4:30 PM, showers were documented at 102°F. There is no documentation when the temperatures were dipping or how long the proper temperatures were maintained after the plumbing company came out to the facility. The Loss of Hot Water Guideline dated 12/13/24 documents, Purpose: To provide guidelines for managing a loss of hot water supply in compliance with health and safety standards while minimizing disruptions to resident care and operations. Responsibilities: Administrator: Oversees emergency response and coordinates with services providers and regulatory agencies .Maintenance Director: Identify the cause of the hot water loss, coordinate repairs, and arranges alternative solutions . Procedures: 1. Report and assess - notify the maintenance director immediately upon discovery of hot water loss, assess the extent of the issue and estimate the time required for repair, and informed the administrator and DON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 4 of 14 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 01/31/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility lacked an effective system to prevent fluid volume overload, assess and monitor fluid volume status, and notify the nephrologist of treatment refusals and abnormal radiology results for one (R8) out of three residents reviewed for dialysis in a total sample of ten. This failure resulted in staff failing to recognize R8's change in condition as fluid volume overload after R8 complained of shortness of breath, and R8 expired in the facility after being found unresponsive. Residents Affected - Few The Immediate Jeopardy began on 1/5/25. When R8 went over 5 days without a dialysis treatment and the facility staff failed to notify the nephrologist of R8's refusal to go the hospital as ordered and failed to notify the nephrologist/attending physician of an abnormal chest X-ray and failed to prevent and assess for fluid volume overload. R8 complained of shortness of breath and later found to be unresponsive. V1 (Asst Administrator) was notified on 1/24/25 at 12:13 PM of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 1.30.25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R8 is a [AGE] year old with the following diagnosis: chronic respiratory failure with hypoxia and hypercapnia, morbid obesity, congestive heart failure, cardiomegaly, lymphedema, end stage renal disease with dependence on renal dialysis, and encounter for tracheostomy and gastrostomy. A Nursing note dated 1/3/25 at 4:30 PM documents R8 refused to go to dialysis. The nurse explained the importance of dialysis and risks for not receiving treatment. The dialysis nurse spoke with the nephrologist who made an order to send R8 to the hospital for an evaluation. A Nursing note dated 1/3/25 at 7:12 PM documents the ambulance arrived for transportation to the hospital, but R8 refused to go. The primary physician was notified. There is no documentation of the nephrologist being notified of R8's refusal to go to the hospital for an evaluation. A Nurse Practitioner note dated 1/4/25 documents R8 was seen today for the initial visit. R8 refused hemodialysis on Friday and discussed concerns. R8 is to resume hemodialysis on Monday. No further orders were put in place to monitor R8 before the next dialysis session. A Nursing note dated 1/5/25 at 4:19 PM documents R8 is receiving continuous oxygen at 3 L via nasal cannula. Vital signs are within normal limits but R8 complains of shortness of breath. R8 continuously requested to go to the hospital. The nurse and management educated R8 on breathing techniques and that vital signs are normal. A chest x-ray was ordered to rule out pneumonia. R8 was also counseled on refusing dialysis treatment and the adverse effects to overall health. R8's family member was notified and reported understanding. There is no documentation that an assessment was completed to listen to R8's lungs or that any vital signs were taken after this point to assess R8 for any further changes in condition or changes in vital signs. A Nursing note dated 1/5/25 at 5:10 PM documents R8 refused to go to the hospital. The nurse educated R8 that R8 should go to the hospital due to refusing dialysis treatments and missing two sessions. R8 voiced understanding after education was provided. A STAT order for labs were put in place. This note was not charted until 10:22PM which is after the time R8 expired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 5 of 14 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 01/31/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The x-ray company's Portable Service Requisition Sheet dated 1/5/25 documents the tech was performing the exam at 6:36PM. R8 was morbidly obese and bedbound. R8 was nonresponsive and physically unable to maintain the lateral position during the exam. A Nursing note dated 1/5/25 at 7:45 PM documents upon rounds, R8 was found without vital signs and was unresponsive. A code blue was called and CPR was initiated. 911 was called. EMS arrived at the bedside but was unable to resuscitate R8. Time of death was called at 8:23 PM. The Emergency Code Documentation dated 1/5/25 documents R8 was found around 7:45 PM by the nurse and had absent respirations, pulse, and blood pressure. CPR was started at this time. EMS arrived at 7:53 PM and took over. R8 expired in the facility at 8:23 PM. The Fire Department Record dated 1/5/25 documents the crew was dispatched to the facility for a full arrest. Upon entering our R8's room, staff from the nursing home were performing CPR and ventilating R8 with a bag valve mask. Staff also stated that R8 missed two dialysis treatments this week. Once placed on the cardiac monitor, it showed asystole for R8's heart rhythm. R8 was given three rounds of medications and CPR with no signs of improvement. The crew called medical control and relayed report. The crew was instructed by the physician to terminate resuscitation efforts with a time of death at 8:23 PM. On 1/14/25 at 1:52PM, V16 (Nurse) stated V16 was the nurse for R8 at the time R8 refused dialysis. V16 reported telling the dialysis company that R8 refused and an order was placed by the dialysis company to send R8 out to the hospital. V16 stated the nephrologist (V22) gave the order to send R8 to the hospital. V16 reported once the ambulance arrive to the facility R8 refused to go to the hospital. V16 reported telling V24 (Primary Physician) that R8 refused to go to the hospital but did not tell V22 (nephrologist). V16 stated V16 worked with R8 on 1/5/25 on the 3 PM to 11 PM shift. V16 reported the previous nurse told V16 a chest x-ray needed to be completed on R8 but V16 was not sure why the chest x-ray was ordered. V16 stated the chest x-ray was completed around 7:30 PM and about 15 minutes later, V16 went to go check on R8. V16 reported at this time R8 was unresponsive, did not have a pulse, and was not breathing. V16 stated a cold blue was called and CPR was started. V16 reported last seeing R8 around 5:30 PM and R8 was using R8's phone. V16 stated checking R8's vital signs around 4:30 PM when V16 arrived to the facility. V16 was unaware of what the x-ray results showed. V16 denied checking the x-ray report and stated it is the responsibility of the doctor. On 1/14/25 at 3:33PM, V18 (CNA) stated V18 came on at 3 PM on 1/5/25. V18 reported this was the first time working with R8. V18 stated the only complaint R8 made was that R8 had a stomach ache and did not want to eat. V18 reported last seeing R8 around 6:30 or 7 PM (This is the time the x-ray was being completed and R8 was noted to be lethargic and unresponsive by V26 (Radiology Technician)) before V18 went on break. V18 stated the V18 was aware R8 skipped dialysis. V18 team reported as V18 was coming back from break, the paramedics were trying to resuscitate R8. V18 denied being aware R8 complained of shortness of breath earlier in the day. On 1/14/25 at 5:20PM, V19 (Nurse) stated V19 took care of R8 during the morning shift on 1/5. V19 reported shortly after breakfast, R8 kept requesting to go to the hospital. V19 stated R8 appeared fine and had normal vitals. V19 denied remembering if R8 reported being short of breath. V19 reported being aware that R8 missed at least one dialysis session. V19 stated V19 did an assessment on R8 and listened to R8's lungs, which were clear. V19 reported V19 did not chart that part of the assessment. V19 stated if you don't chart what a nurse does then it is considered that it wasn't done. V19 reported last seeing R8 between 1:30 and 2:30 PM. V19 stated R8 was sleeping during this last set of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 6 of 14 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 01/31/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few rounds and V19 did not wake R8. V19 denied remembering why a chest x-ray was ordered. V19 reported R8 stated that R8 felt panicked and was getting anxious so V19 talked R8 through some breathing exercises to calm down. V19 stated a chest x-ray was put in STAT but does not know why the x-ray was not completed on V19's shift. V19 reported fluid builds up in the body when dialysis is missed. On 1/15/25 at 10:38AM, V20 (Dialysis Nurse) stated V20 was aware that R8 refused dialysis on 1/3. V20 reported calling the nephrologist (V22) to notify of the refusal. V20 reported that V22 ordered to send R8 to the hospital for an evaluation. V20 stated it is the facilities responsibility to send R8 to the hospital. V20 denied being aware that R8 did not go to the hospital. V20 reported if V20 was made aware then V20 would have called the nephrologist to update V22 and get any further orders. V20 stated if a resident skips dialysis then they can become fluid overloaded. V20 reported fluid overload can begin anywhere from one day to three days after missing a treatment. On 1/15/25 at 11:43AM, V21 (Nurse Practitioner) stated V21 was aware that R8 refused dialysis on 1/3. V21 reported telling R8 that if R8 became short of breath that R8 would need to go to the hospital to be dialyzed. V21 stated V21 did not follow up with R8 on 1/5 because when V21 saw R8 the day before, R8 was stable. V21 reported vital signs were being done each shift on R8 so no other orders needed to be put in. V21 stated V21 did not put in any further orders to monitor for fluid overload because R8 was stable the last time R8 was assessed by V21. On 1/15/25 at 12:03PM, V22 (Nephrologist) stated V22 had a very good rapport with R8 and followed R8 since R8 began dialysis at the hospital. V22 reported being aware that R8 refused dialysis on 1/3. V22 stated that an order was put in to send R8 out to the hospital for an evaluation. V22 denied that any staff made the dialysis center or V22 aware that R8 refused to go to the hospital. V22 stated V22 was under the impression that R8 went to the hospital and got dialysis there. V22 reported R8 does not have a healthy heart or lungs to be skipping treatments without issues. V22 stated if a dialysis patient tells you they are short of breath then they need emergent dialysis. V22 reported V22 wanted to be involved if R8 was continuing to refuse care due to having a close relationship with R8. V22 stated V22 would have continued to speak with R8 or even come in to talk to R8 until R8 agreed to go to the hospital. V22 reported V22 would have gotten to the root of why R8 was refusing to go to dialysis. V22 stated that if V22 was aware that R8 did not go to the hospital that at a minimum labs and chest x-rays would have been ordered daily over the weekend. On 1/15/25 at 12:21PM, V23 (Nurse Manager) stated V23 was aware that R8 refused dialysis on 1/3. V23 reported V23 began looking through orders and realize the facility had nothing going on for him. V23 suggested getting labs and a chest x-ray to get a baseline. V23 denied R8 received any dialysis since R8 was admitted on 12/31. V23 reported vital signs were completed once a shift to monitor R8. V23 stated the facility staff communicate with a primary physician and dialysis staff communicates with the nephrologist. V23 reported if R8 was symptomatic then R8 would've been sent out to the hospital immediately. V23 stated all orders were put in STAT due to it being a weekend and it would have been a long wait if put in as a standard order. V23 reported they needed to be updated on R8's status on that day. V23 denied being aware that R8 complained of being short of breath. On 1/15/25 at 12:45PM, V1 (Asst. Administrator) stated V1 was at the facility but stepped out of the building at the time R8 was found unresponsive. V1 reported upon returning to the facility, V1 saw the paramedics and learned R8 expired. V1 stated V1 was made aware that R8 skipped dialysis on 1/3/25 and refused to go to the hospital. V1 reported the plan was to have a conversation with R8 on 1/6/25 to see if R8 wanted to continue dialysis or be put on hospice. V1 stated R8 had a chest x-ray and labs ordered on 1/5 because R8 refused dialysis. V1 reported V24 (Primary Physician) was made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 7 of 14 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 01/31/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few aware every time R8 refused dialysis or to go to the hospital. V1 stated only the dialysis nurses communicate with the nephrologist (V22). V1 reported it was portrayed that V22 put in the order for R8 to go to the hospital. V1 was not aware if V22 was called after R8 refused to go to the hospital. V1 reported the results to the x-rays are automatically uploaded to the computer system. V1 stated the nurse is responsible to read the results and notify the physician if there's any abnormalities. V1 reported if R8 was having any symptoms of fluid overload, R8 would have needed to go to the hospital and would not have had a choice at that point. V1 stated vital signs and head to toe assessments were performed each shift to monitor R8 for fluid overload. On 1/15/25 at 1:56PM, V24 (Primary Physician) stated R8 refused dialysis and refused to go to the hospital on 1/3. V24 reported R8 asked to go to the hospital again on 1/5 due to a change in condition. V24 was unable to remember what the change of condition was. V24 stated if dialysis is refused or sessions are missed that the body can fill up with fluid. V24 reported the results of R8's chest x-ray indicate R8 would've had some kind of pneumonia and that the pleural fluid was meaning that R8's heart was filling up from fluid due to the kidneys, not working. On 1/16/25 at 12:40PM, V25 (Radiology Director of Operations) stated once the facility puts in order for an image to be taken, it gets electronically sent over to the radiology company. V25 reported the x-ray was ordered for R8 and assigned to a technician at 11:39 AM. V25 reported STAT orders are normally taken between 4 to 6 hours. V25 could not answer why the x-ray was not completed within 4 to 6 hours but reported the facilities are aware that if the STAT x-ray is not completed within this timeframe, they can decide what to do by calling the physician for notification. V25 stated the facility has bidirectional access which allows them to see results once they are uploaded into the computer system after being reviewed by radiologist. V25 reported the results to the chest x-ray for R8 were uploaded into the system at 6:52 PM. On 1/17/25 at 10:05AM, V1 stated STAT x-rays are usually done with in 4 to 6 hours. V1 reported sometimes the x-rays aren't taken in that time frame. V1 stated if a resident declines any further or shows symptoms of anything then they are sent out to the hospital immediately. On 1/18/25 at 11:10AM, V26 (Radiology Technician) stated V26 got to the facility and took the ordered chest x-ray around 6:30PM. V26 reported R8 was lethargic and would not respond to any questioning. V26 stated V26 exited the room before doing the exam to ask an unknown CNA if this was R8's normal state. V26 reported the CNA told V26 that it was normal for R8 to act unresponsive and did not go into the room to check on R8. V26 stated since R8 was not able to follow directions or move, V26 was only able to get a one view chest x-ray when a two view was ordered. V26 denied R8 being able to roll onto R8's side. V26 reported out of the 17 images, 11 of them were scheduled to be STAT that day. V26 denied the facility calling and checking on the status of when the x-ray would be taken. V26 reported normally if a resident cannot move staff will come in and assist, but no staff was available to help during the time of this x-ray. On 1/21/25 at 1:17PM, V19 stated V19 received an order to send R8 to the hospital on 1/5 but R8 changed R8's mind. V19 again denied remembering if R8 complained of being short of breath V19 was shown the note that was written by V19 on /5/25. V19 said, Apparently he was complaining of shortness of breath after I read my note. V19 denied remembering what time R8 complained of shortness of breath. V19 reported checking R8's vital signs one time during that shift. V19 reported getting an order for a chest x-ray from V27 (Nurse Practitioner). V19 stated V24 (Primary Physician) gave the order to send R8 to the hospital. V19 reported an order should be put into the computer system as soon as they are received V19 denied remembering why the orders were put into the computer system by V19 after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 8 of 14 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 01/31/2025 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 0698 10 PM. Level of Harm - Immediate jeopardy to resident health or safety On 1/21/25 at 1:39PM, V27 (Nurse Practitioner) stated V27 was not called or notified about R8's change in condition. V27 reported at the time of R8's change in condition another physician's group covers for needs of the residents. V27 denied having any involvement in R8's care. Residents Affected - Few On 1/21/25 at 2:13PM, V24 stated staff needs to call V24 to verify all orders before putting them in the computer system. V24 stated the order should be put into the computer system as soon as V24 agrees to it so it can be completed as soon as possible. V24 denied remembering what orders staff suggested for R8 on 1/5. V24 denied remembering why the chest x-ray was ordered for R8 on 1/5. V24 said, If the order says congestion, then I guess he was having some congestion. We have to put in a reason for every x-ray so the radiologist knows what they're looking for. V24 denied that staff ever called V24 to report a change in condition where R8 needed to be sent out via 911. V24 stated if a resident has a change then V24 must be notified, but if it is serious, then staff must send out the resident via 911 as soon as possible. The admission Hospital Records dated 12/31/24 document R8 originally came to the hospital on [DATE] after being found hypoxic due to pneumonia. R8 suffered sepsis and multi organ failure. R8 began hemodialysis for acute renal failure, experienced cardiomegaly with congestive heart failure, respiratory failure, and needed a tracheostomy as well as gastrotomy tube placed. R8 received hemodialysis on Tuesdays, Thursdays, and Saturdays at the hospital. R8 received dialysis on 12/30/24 and had 3 L of fluid removed. R8 received dialysis again on 12/31/24 and had 3.4 L of fluid removed. R8 was given an extra session of dialysis before discharge and anticipation of being admitted to a new facility. Upon discharge, R8 had no significant volume overload. The admission Evaluation dated 12/31/24 documents R8 is only able to urinate small amounts. Breath sounds upon admission are documented as clear bilaterally. The Physician Order Summary documents a STAT chest x-ray was ordered on 1/5/25 at 11:38 AM. An order was placed on 12/31/24 for R8 to receive hemodialysis on Mondays, Wednesdays, and Fridays. More orders were placed to send R8 to the hospital and or STAT CBC and CMP (laboratory work) on 1/5/25. After reviewing the order details, the orders for the transfer to the hospital and laboratory work was put in on 1/5/25 at 10:10PM. These orders were placed almost 2.5 hours after R8 was found unresponsive. The Radiology Report dated 1/5/25 documents the results of the chest x-ray showed bilateral lung infiltrates, pericardial effusion, and pulmonary vascular congestion. The Order Information Sheet from the x-ray company documents the company was notified of the chest x-ray order at 11:39 AM on 1/5/25. The order priority did come in as STAT. The technician arrived to the facility at 6:36 PM and completed the exam at 6:38 PM. The reason documented for ordering the exam is congestion. The results of the chest x-ray were read by the radiologist at 6:49 PM and uploaded into the computer system the facility could access at 6:52 PM. The chest x-ray did have a positive critical finding. The Care Plan dated 1/3/25 documents R8 is resistant to care related to anxiety and adjusting to the nursing home. R8 is currently on hemodialysis however R8 still eats food not listed on the renal diet and is resistant to care including dialysis and other care. There are no interventions or protocols on what to do when R8 refuses a dialysis treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 9 of 14 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 01/31/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The policy titled Refusal of Treatment, dated 08/2008 documents, Policy Interpretation and Implementation: .3. If a resident/resident's clinical representative refuses treatment, the unit manager, charge nurse, director of nursing services, or designee will interview the resident to determine what and why the resident is not adherent to the plan of care in order to try to address the resident's concerns and explain the consequences. 4. The care plan team will assess the resident's needs and offer the resident alternative treatments, if available, while continuing to provide other services outlined in the care plan. 5. If the resident's refusal brings about a significant change, a reassessment will be made, and such information will be incorporated into the resident's care plan. 6. The attending physician must be notified of such refusal, consistent with facilities policy and accepted standard of practice. The policy titled, Notification of Change, dated 7/1/24 documents, Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and are reported to and consulted with the attending physician. The resident and/or the resident representative will be educated about treatment options and supported to make informed decision . Objective of the Notification of Change Guideline: The objective of the notification guideline is to ensure facilities staff make appropriate notification to the physician or delegated non-physician practitioner in immediate notification to the resident and/or the resident representative when there is a changing condition. Requirements for Notification of Resident, the Resident Representative, and their Physician: A significant change in the resident's physical, mental, or psychosocial status - A significant change includes deterioration and health, mental, or psychosocial status in either life-threatening conditions or clinical complications and/or a need to alter treatment significantly . Physician Notification and Consultation: Notification is provided to the physician to facilitate continuity of care and obtain guidance from the physician about changes or additions to or discontinuation of treatments . Procedure: 1. Obtain orders for appropriate treatment in monitoring and promote the residents right to make choices about treatment and care preferences 2. Document the notification and record any new orders in the resident's medical record. 3. Educate the resident and/or representative about the proposed plan to treat, manage, or monitor the resident's change in condition 4. Educate the resident and/or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of treatment 5. Update the resident's care plan, transcribe, and implement the providers orders 6. Communicate the changes to the care team and pharmacy. The Facility Agreement with the x-ray company dated 9/12/24 documents, .Duties and Obligations of the Facility: .f. Facility agrees to provide a clinician/staff member to be present and assist when a service is performed. The facility in-services were reviewed. The In-service on 10/15/24 and 10/23/24 document the in-service was provided to nursing staff (CNAs and nurses) about changes in condition. Topics covered include: a change in condition must be reported to the RN or MD when first noted, STAT orders must be completed within 4 hours and if not then the MD must be notified, and nurses are expected to know abnormal lab values and diagnostic results - if the MD does not provide orders for the abnormal result then it must be questioned why. The Immediate Jeopardy that began on 1.5.25 was removed on 1.31.25 when the facility took the following actions to remove the immediacy. Abatement plan 698 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 10 of 14 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 01/31/2025 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 0698 R8 is no longer a resident in the facility. Level of Harm - Immediate jeopardy to resident health or safety All current 22 dialysis residents were assessed for potential fluid overload, intervention in place as appropriate. There are no current dialysis residents refusing dialysis treatment currently. Residents Affected - Few Licensed nurses were educated 1/24/25 by the Director of Nursing on the need to assess and implement interventions related to fluid volume overload when residents miss dialysis treatments. Dialysis assessment orders were updated per their physician. Their assessment order reads: Monitor for signs and symptoms of fluid volume overload, edema, bloating, headache, weight gain, shortness of breath, elevated blood pressure, JVD, lung sounds with crackles or wheezing, abdominal distention, or tachycardia. This assessment will be completed every shift and PRN. Licensed nurses were educated by the Director of Nursing on 1/24/25 on the importance of notifying the Attending physician and if unable to reach him/her notifying the resident's Nephrologist. Licensed nurses were educated 1/24/25 by the Director of Nursing if STAT radiology orders are not able to be completed within the recommended 4-6 hours the provider will be notified for additional instructions. Licensed Nurses will not work until they have been educated. Radiology company (All-Stat) has been notified of the expectation of timely notification of abnormal radiology results. Based on information from the radiology provider, x rays have an approximate read time of 90 minutes. Once the radiology company's quality controls has reviewed the results the results will be uploaded into the electronic health record. Nurses will obtain the information from the record at that time and notify physician accordingly. Licensed nurses were educated on 1/30/25 to review their electronic health records within 90 minutes to check and communicate the results of the radiology report. An additional email notification system has been implemented with the radiology company. This ensures all nursing managers receive results as they are uploaded into the electronic health record. All nursing managers were educated on 1/30/25 on the additional notification system. The Director of Nursing will audit weekly all residents who refused dialysis to ensure they have been assessed, appropriate interventions are implemented, and that the physician was made aware. In the event that the resident's physician was not made aware, she will ensure that the Nephrologist was. The Director of Nursing will complete weekly audits x 3 months to ensure any STAT radiology orders were completed within the recommended 4-6 hour timeframe, and if the physician was notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 11 of 14 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 01/31/2025 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 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 on observation, interview, and record review, the facility failed to repair a heat exchanger and maintain the hot water system in functioning condition to ensure that hot water was provided to the second, third, and fourth floor shower rooms. Residents Affected - Some Findings Include: R1 is a [AGE] year old with the following diagnosis: spinal stenosis, fibromyalgia, and lumbar disc degeneration. The Facility Incident Report Form dated 1/4/25 documents at 10AM on this day the facility experienced suboptimal water temperatures. Plumbers were called out to assess the situation and identified the cause of the problem. Staff and residents were made aware of the situation. The hot water system currently operational and returned back to normal use. Water temperatures were tested to ensure compliance. On 1/7/25 at 12:40PM, the surveyor asked V2 (Maintenance Director) to take water temperatures in the facility. V2 stated that the plumbing company is currently working on cleaning the part so the water tank is not on so all water temperatures in the facility would be suboptimal. The surveyor notified that water temperatures would need to be taken at some point during the day. V2 stated V2 first noticed the temperatures dropping on the water tanks on 1/3/25 and a plumbing contractor was called out immediately. V2 reported the plumbing company notified V2 there was an issue with the heat exchanger. V2 reported normal water temperatures in the facility range form 105-109 degrees F. V2 stated the temperature should stay between 100-110 degrees F for residents. V2 stated scheduled maintenance should be completed twice a year. V2 reported V2 did not know when the last time scheduled maintenance was completed on the water heater due to V2 just starting at the facility in October. V2 denied completing scheduled maintenance on the boiler since starting in October. On 1/7/25 at 2:57PM, V1 (Assistant Administrator) stated V1 was not sure when maintenance or checks are supposed to be completed but V2 is responsible for making sure the equipment is in working condition. V1 reported V2 either repairs the equipment or calls out a contractors to make repairs when needed. V1 stated V1 was notified of the showers not having hot water on 1/4/25. V1 reported the plumbing company was called out on Friday (1/3/25) to clean the heat exchanger and told the facility 1/4/25 that the part would need to be replaced. On 1/7/25 at 3:50PM, V2 took the surveyor into the boiler room. The thermometer on the hot water tank was 151 degrees Fahrenheit (F). V2 reported this water comers in from the reservoir tank and that tank stays at 115 degrees F. V2 stated the water from the hot water tanks comes out of that tank and mixes with the reservoir tank and goes out into the pipes up to the floors at 128 degrees F. V2 reported the plumbing company took off the heat exchanger and cleaned all the sediment out of the part then replaced new copper piping which was completed at 3:20PM so the cold water is not fully cleared out of the tanks yet. V2 then took V1 (Assistant Administrator) and the surveyor to the floors to take water temperatures. At 3:53PM, room [ROOM NUMBER] sink was tested by V2 and was 104 degrees F. V2 then turned on the water of the third floor north shower room at 3:55PM. V2 let the water run until 4:01PM and then took the temperature. The temperature of the shower water was 55 degrees F. At 4:03PM, room [ROOM NUMBER] sink was 108 degrees F and the shower in this room was 74 degrees F. V2 then turned on the water of the fourth floor north shower room at 4:05PM. The temperature of the water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 12 of 14 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 01/31/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in this shower room at 4:06PM was 68 degrees F. V2 then stated the water in the shower rooms on the second floor would be a suboptimal temperature as well due to the pipes still having cold water in them from earlier in the day. V2 reported it would take two to three hours for the water to be running within range again. On 1/7/25 at 4:21PM, V9 (Site Manager) stated V9 was notified 1/6/25 that the boiler was not properly functioning. V9 reported V9 talked to the contractor immediately and the contractors began ordering the part needed to repair the boiler. V9 said, I have no idea why I was notified yesterday. I don't know why I was not told about it sooner. V9 stated V9 has the responsibility of approving proposals from the contractors but V9 needs to be made aware of the issues in the facility and be told by the facility that a proposal is ready to be reviewed. V9 denied being made aware of the proposal for the broken heat exchanger until 1/6/25. V9 reported V9 should have been made aware of the issues with the boiler as soon as the temperatures were dropping. V9 stated it is up to the facility to determine how and when maintenance is performed on the equipment to keep it functioning. On 1/9/25 at 9:45AM, V2 stated from 1/3/25 to 1/7/25 the plumbing company progressively tried different methods to get the water temperatures within range, but it ultimately took until 1/7/25 for optimal temperatures to be maintained. V2 reported the heat exchange part that needs to be replaced is still in route to the facility and will be put on as soon as it arrives. V2 stated water temperatures were taken every two hours while V2 was in the facility but V2 only documented the temperatures once a day. The Service Request dated 1/3/25 documents a service was requested for the water heaters in the mechanical boiler room due to no hot water. The heat exchange coil is malfunctioning and needs immediate attention. This request was created at 9:38 AM. A technician arrived to the facility at 12:05 PM. The technician departed the facility at 5:59 PM, but the work for this job was not yet completed. The issue is temporarily fixed and a quote is needed. The technician suggested the unit will need a new heat exchanger at the minimum to be operational. There is no documentation that the plumbing company was in the facility on 1/4/25. The Service Request dated 1/5/25 documents the plumbing company was called out to the facility at 11:10 AM. The technician arrived and completed services from 12:26 PM to 3:05 PM. It is documented that the servicing cost is not to exceed $6750 per the facility's documented not to exceed limit. The technician documented the work for the facility is not yet completed because the not to exceed limit has not been adjusted or approved. No work can be completed without a higher estimate for the job being given to the plumbing company. The plumbing manager spoke with the facility corporate regarding this repair and will follow up. The boiler plate has cracks and needs to be welded, and additional repairs may be needed after [NAME] process is started as the overall condition of the steel is unknown. If additional work is required, the not to exceed limit needs to be increased and submitted for approval. The Project Proposal dated 1/4/25 was created on this day and a pending service quote is needed. On 1/7/25 at 10:04 AM the quote is still pending approval. At 11:32 AM, the quote was accepted and authorized by V9. The Finalized Proposal dated 1/7/25 documents the maintenance director requested service for the water heaters and upon inspection, the technician determine that at a minimum, the unit requires a new heat exchanger to become operational. Work is expected to start on site within the next 2 to 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 13 of 14 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 01/31/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm days following approval of the proposal and availability of the part. A heat exchanger was ordered on this day. The total cost of the materials, labor, and expedited shipping cost $24,794. The surveyor requested maintenance/service logs on the water heater system but V2 was unable to provide the requested documentation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 14 of 14