Health inspection·February 7, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 follow their Answering the Call Light Policy. The facility failed to place the call light within reach. This deficient practice affects one resident (R58) of three residents reviewed for accommodation of needs in a total sample of 55 residents. Residents Affected - Few Findings Include: On 2/4//25 at 11:00AM observed R58 In bed alert and oriented x 3. R58 is with the BIMS score of 15/15 (Cognitively Intact). R58 asked writer where her call light location. Surveyor observed call light clipped next to her head pillow on R58 right side of the head, lateral to her right ear. Asked R58 if she is able to reach call light and R58 was not able to reach call light. R58 stated that she has contracture and left arm cannot reach to the location of her call light. Surveyor unclipped her call light and place and clipped it near R58 left hand, by chest area. R58 now can reach the call light and happy with the new call light placement. On 2/6/25 at 12:15PM, V9 (Restorative Nurse) stated that R58 has severe bilateral hand and finger contracture and not able to open finger and grab call light if it not place by her chest area. R58 will need the call light by her chest area, so she can hit the light button with her chin or press it against her chest to use. If the call light is place close to her head she won't be able to reach and grab it because she is not able to open her hand and fingers. R58's Joint Mobility assessment dated [DATE], reads in part: Right wrist and Left wrist: moderate, (51-75% available Range of Motion). Right and left fingers/hand: severe (0-25% available Range of Motion). Answering the Call Light Policy with a revised date of August 2008, reads in part: The purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FACILITY Environment Based on observation, interview and record review, the facility failed to follow their Answering the Call Light Policy. The facility failed to place the call light within reach. This deficient practice affects one resident (R58) of three residents reviewed for accommodation of needs in a total sample of 55 residents. Findings Include: On 2/4//25 at 11:00AM observed R58 In bed alert and oriented x 3. R58 is with the BIMS score of 15/15 (Cognitively Intact). R58 asked writer where her call light location. Surveyor observed call light clipped next to her head pillow on R58 right side of the head, lateral to her right ear. Asked R58 if she is able to reach call light and R58 was not able to reach call light. R58 stated that she has contracture and left arm cannot reach to the location of her call light. Surveyor unclipped her (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 02/07/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few call light and place and clipped it near R58 left hand, by chest area. R58 now can reach the call light and happy with the new call light placement. On 2/6/25 at 12:15PM, V9 (Restorative Nurse) stated that R58 has severe bilateral hand and finger contracture and not able to open finger and grab call light if it not place by her chest area. R58 will need the call light by her chest area, so she can hit the light button with her chin or press it against her chest to use. If the call light is place close to her head she won't be able to reach and grab it because she is not able to open her hand and fingers. R58's Joint Mobility assessment dated [DATE], reads in part: Right wrist and Left wrist: moderate, (51-75% available Range of Motion). Right and left fingers/hand: severe (0-25% available Range of Motion). Answering the Call Light Policy with a revised date of August 2008, reads in part: The purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. . 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 02/07/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent and incident of staff to residents verbal abuse and rough handling during direct care. This affected one of three (R179) residents reviewed for abuse in a total sample of 55. Findings Include: R179 is a [AGE] year old with the following diagnosis: pedestrian injured in traffic accident, traumatic subarachnoid hemorrhage with loss of consciousness, fracture of the thoracic vertebra, avulsion fracture of the ilium, and intervertebral disc degeneration. On 2/4/25 at 11:32AM, R179 stated V21 (CNA) yelled at R179 after R179 told V21 to stop going through R179's personal belongings. R179 reported that V21 screamed at R179 to shut the f*ck up and to not tell V21 what to do. R179 reported V21 then began to provide incontinence care and scrubbed R179's groin area to the point it was sore. R179 stated R179 reported this incident to V13 (Nurse) on 2/4/25 at about 8PM. R179 reported V13 told R179 that V21 will no longer work with R179. On 2/5/25 at 1:32PM, V13 stated on Monday (2/4/25) sometime in the evening R179 reported V21 yelled at R179 and was rough while changing R179. V13 reported telling V8 (ADON) about the allegations because this would be considered an physical and verbal abuse. V13 stated R179 is alert and oriented and knows how to make needs known. V13 reported telling V21 to not work with R179 anymore that shift and assured R179 that V21 would no longer work with R179. On 2/6/25 at 1:46PM, V21 stated V21 and R179 did not have any problems with each other while providing care. V21 denied yelling at R179 or being too rough with R179 while providing incontinence care. V21 reported V21 was going through R179's dressers to look for a brief but asked R179 permission first. V21 reported R179 granted permission to go through the drawers but then told V21 to get out of the drawers. V21 stated V21 closed the drawer when R179 asked. V21 denied R179 reporting to V21 that R179 was upset with V21 for being too rough or yelling. The Facility Incident Report Form dated 2/5/25 documents R179 is alert and oriented times three and able to make needs known. R179 alleged V21 provided care too quickly and was upset with V21 while V21 was providing care. An investigation was initiated. The policy titled, Abuse Prevention Policy, dated that is not dated 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. 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 anguish 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 .Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individual's age, ability to comprehend, or disability. 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 02/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of verbal and physical abuse to Illinois Department of Public Health within 24 hours. This affected one of three (R179) residents reviewed for abuse policy in a total sample of 55. Findings Include: R179 is a [AGE] year old with the following diagnosis: pedestrian injured in traffic accident, traumatic subarachnoid hemorrhage with loss of consciousness, fracture of the thoracic vertebra, avulsion fracture of the ilium, and intervertebral disc degeneration. On 2/4/25 at 11:32AM, R179 stated V21 (CNA) yelled at R179 after R179 told V21 to stop going through R179's personal belongings. R179 reported V21 then began to provide incontinence care and scrubbed R179's groin area to the point it was sore. R179 stated R179 reported this incident to V13 (Nurse) on 2/4/25 at about 8PM. R179 reported V13 told R179 that V21 will no longer work with R179. On 2/5/25 at 1:32PM, V13 stated on Monday (2/4/25) sometime in the evening R179 reported V21 yelled at R179 and was rough while changing R179. V13 reported telling V8 (ADON) about the allegations because this would be considered an allegation of abuse that needs to be reported immediately. On 2/5/25 at 4:07PM, V8 stated V8 was just notified five minutes before coming down to talk to the surveyor about the allegations. V8 denied being told about the incident before today. V8 stated staff should immediately report the problem to the administrator. On 2/6/24 at 1:02PM, V7 (Administrator) stated V7 was told yesterday bout 5PM that R179 was unhappy about the care V21 provided to R179. V7 reported R179 told V7 that V21 was too rough when providing care and rushed through care. V7 denied being told about the incident before yesterday at 5PM. V1 stated staff should report any allegation of abuse immediately. The Facility Incident Report Form dated 2/5/25 documents R179 is alert and oriented times three and able to make needs known. R179 alleged V21 provided care too quickly and was upset with V21 while V21 was providing care. An investigation was initiated. The policy titled, Abuse Prevention Policy, dated that is not dated documents, 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 anguish to a resident .Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public health immediately, but no more than two hours of the allegation of abuse. 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 02/07/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate to ensure a resident had a completed level II PASRR assessment on a resident with sever mental illness. This affected one of five (R179) reviewed for PASRR screening in a total sample of 55. Findings Include: R179 is a [AGE] year old with the following diagnosis: major depressive disorder and schizoaffective disorder. R179 admitted to the facility on [DATE] with the diagnoses listed above per the face sheet. On 2/5/25 at 12:34PM, R179 was not aware of Maximum completing a level II PASRR. R179 admitted to being diagnosed with major depressive disorder and schizoaffective disorder. R179 reported R179 takes medication for these mental health diagnoses. On 2/6/25 at 12:55PM, V14 stated R179 was admitted to the facility with a diagnosis of schizoaffective disorder and major depression. V14 reported V14 confirms the PASRR level I screen with the face sheet diagnosis to determine if the screening is correct. V14 stated R179 should have a level II screen based on R179's diagnosis, and V14 must have missed it. V14 denied R179 having a level II screen as of today. The PASRR Level I Screen dated on 11/8/24 documents R179 does not have any known mental health diagnosis and no level II is recommended. This is incorrectly documented as R179 has a diagnosis of schizoaffective disorder which would qualify R179 for a level II screen. On 2/6/25 at 1:35PM, V14 stated R179 had the level I screen correctly documented to show R179 has a mental health diagnosis. V14 reported based on this screening, Maximus will be notified and come out to perform the level II screen. 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 02/07/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the hospital discharge orders for a resident by not ensuring a prescribe wound vac was applied for two days. This affected one of one (R439) residents reviewed for physician orders. Residents Affected - Few Finding Includes: R439 was admitted on [DATE] with the diagnosis of surgical aftercare following surgery on the digestive system. Hospital paperwork dated 2/3/25 documents: discharge instruction place wound vac at skill nursing facility. Physician order sheet dated 2/3/25 documents: may apply wound vac to affected area. On 2/4/25 at 10:43am, R439 who was assessed to be alert and oriented to person, place and time, said, he has not received his wound vac as ordered since his admission. R439 said, he had the wound vac in the hospital after his surgery and it supposed to be continued upon discharge. R439 was observed without a wound vac attached to his surgical wound located on R439's abdomen. R439 did not have a wound vac in his room. On 2/5/25 at 11:54am, R439 said, his wound was still not applied. R439 was observed without a wound vac on his surgical wound located on his abdomen. On 2/5/25 at 3:54pm, V6 (treatment nurse) said, we don't preorder wound vacs. R439 does not have a wound vac. It has been two days. We ordered the wound vac. A wound vac speeds up the healing of the wound. On 2/5/25 at 4:15pm, V8 (adon) said, R439 wound vac should have been order prior to his admission so that it could have been applied as soon as he arrived at the facility. It should have been in place because it was in place at the hospital, ordered upon discharge and for continuity of care. On 2/6/25 at 1:07pm, V8 (adon) said, we did not have any wound vac in the facility upon R439 admission or prior to yesterday when it was delivered. Facility order sheet dated 2/5/24 documents: Patient: R439 state -pending acceptance. Requested 2/4/25 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 02/07/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide restorative programming for a resident after the resident was referred to restorative therapy upon discharge from physical therapy. This affectes one of three (R179) reviewed for restorative nursing. Findings Include: R179 is a [AGE] year old with the following diagnosis: pedestrian injured in traffic accident, traumatic subarachnoid hemorrhage with loss of consciousness, fracture of the thoracic vertebra, avulsion fracture of the ilium, and intervertebral disc degeneration. On 2/5/25 at 12:34PM, R179 stated R179 received about one week of physical therapy before being discharged . R179 was not aware what the recommendations were after being discharged from physical therapy. R179 denied receive any services or programs to help R179 with movement or getting out of bed. R179 reported R179 has not been out of bed since before 12/25/24. R179 stated R179 needs assistance with turning in bed and standing. R179 it would be beneficial to R179 to be working on maintaining R179 current activity level to prepare for when R179 is discharged . On 2/6/25 at 3:33PM, V20 (Certified Occupational Therapy Assistant) stated R170 was discharged from physical therapy due to R179's decision to not pay for any sessions privately. V20 reported R179 received a total of three sessions before being discharged . V20 stated based on the discharge summary R179 was recommended to receive restorative therapy for range of motion after being discharged . V20 reported this is recommended to help the resident continue to move. V20 stated R179 needed maximum assistance with all therapy. On 2/6/25 at 3:45PM, V9 (Restorative Nurse) stated residents are screened upon admission and quarterly and this determines what restorative nursing programs the resident requires. V9 reported after discharge from therapy, therapy will email or give in writing the recommendations for each resident. V9 denied receiving any recommendations for R179 after R179 was discharged from therapy. V9 stated V9 was aware R179 discharged from therapy and did not check on the recommendations. V9 reported R179 did not want to participate in the assessment upon admission due to pain so R179 was assessed at having moderate to severe join limitation. V9 denied reassessing R179 mobility and restorative needs when R179 was in less pain. V9 stated the restorative programming charting is locate din the point of care charting. V9 confirmed R179 had no charting in the computer system for restorative programs. V9 denied R179 receiving any restorative therapy programming. The Joint Mobility Screen dated 11/13/24 documents R179 has either moderate/severe to severe limitations with every joint and range of motion. It is documented R179 is in a lot of pain at the time and declined an evaluation. The Physical therapy Discharge summary dated [DATE] documents R179 received physical therapy services from 12/3/24 through 12/18/24. R179 was recommended to the restorative range of motion program due to needing partial to moderate assistance with transfers and walking. V9 stated V9 will have R179 reassessed today (2/6/25). The Joint Mobility Screen dated 2/6/25 documents R179's range of motion is within limits for all joints. (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 02/07/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Care Plan that has no date documents R179 has a an ADL self-care performance deficit. R179 needs maximum two person staff assist with bed mobility and needs maximum one person staff assist with bathing and dressing. There is no documentation that R179 participates in any restorative therapy. The Physician Order Sheet was reviewed and there is no order for R179 to receive restorative therapy. The Point of Care charting was reviewed and there is no documentation that any restorative services have been offered to R179 by staff. The policy titled, Rehabilitative Nursing Care, dated 04/2007 documents, Policy Statement: Rehabilitative nursing care is provided for each resident admitted . Policy Interpretation and Implementation: .2. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. 3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. 4. Rehabilitative nursing care is performed for those resident's who require such service. Such program include, but is not limited to: a. maintaining good body alignment and proper positioning; b. encouraging and assisting bedfast residents to change position at least every two hours; c. making every effort to keep residents active and out of bed for reasonable periods of time, except when contraindicated .5. Through resident care plan, the goals of rehabilitative nursing care are reinforced in the Activities Program, Therapy Services. 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 02/07/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to follow their storage of medication policy by not labelling eye drop vials after opening and using drops for four of four (R169, R135, R127 and R178) resident reviewed for medication storage policy and procedure. Findings include: On 2/4/25 at 3:40pm, R169 had Brimonidine Ophthalmic Solution and Dorzolamide HCl Ophthalmic Solution was on the medication cart opened and not dated. V3 (nurse) said, R169's eye drops were opened, used and not dated. Physician order sheet dated 2/1/25 documents: Brimonidine Tartrate Ophthalmic Solution Instill 1 drop in both eyes three times a day for glaucoma. Dorzolamide HCl Ophthalmic Solution Instill 1 drop in both eyes two times a day for glaucoma. On 2/4/25 at 3:40pm, R135 had Brinzolamide Ophthalmic Suspension was on the medication cart opened and not dated. V3 (nurse) said, R135 eye drops were opened, used and not dated. Physician order sheet dated 2/1/25 documents: Brinzolamide Ophthalmic Suspension Instill 1 drop in both eyes three times a day for unspecified glaucoma. On 2/4/25 at 4:44pm, R127 had Latanoprost Solution was on the medication cart open and not dated. V4 (nurse) said, R127 eye drops were opened, used and not dated. Physician order sheet dated 2/1/25 documents: Latanoprost Solution Instill 1 drop in both eyes at bedtime glaucoma. On 2/4/25 at 4:44pm, R178 had Azelastine Ophthalmic Solution was opened and not dated. V4 (nurse) said, R178 eye drops were opened, used and not dated. Physician order sheet dated 2/1/25 documents: Azelastine HCl Ophthalmic Solution Instill 1 drop in both eyes two times a day for conjunctivitis. On 2/5/25 at 4:34pm, V10 (don) said, when the eye drops are open the bottle must be dated with the opened date. The bottle has an expiration dated but when it open it must be dated by the nurse. Storage of medication dated 10/25/2014 documents: when the original seal of a manufacturer's containers or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the, medication and enter the date opened and the new date of expiration. 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 02/07/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the influenza and pneumococcal vaccine and provide education in a language a resident understood. This affectes one of five (R169) residents reviewed for vaccinations in a total sample of 55. Residents Affected - Few Findings Include: R169 is a [AGE] year old with the following diagnosis: type 2 diabetes, end stage renal disease with dependence on hemodialysis, congestive heart failure, and peripheral vascular disease. The facility vaccination log was reviewed during the annual survey process. R169 was randomly selected to check compliance with vaccination status. On 2/6/25 at 12:34PM, V12 (Infection Prevention Nurse) stated the facility hold vaccinations clinics beginning in September and calls out the vaccine company as needed to make sure all residents are vaccinated. V12 was unable to provide the exact dates but reported the vaccine clinics have been held in 09/2024, 10/2024, and 01/31/2025. V12 stated R169 was first asked about the vaccines in 09/2024 and R169 refused the vaccines at that time. V12 reported residents are asked before every vaccine clinic to determine if the residents want the vaccine or still refuse. V12 stated R169 should have been asked before each clinic and there should be documentation R169 refused each time. V12 reported R169 requested to have the vaccines on 12/31/24 when the informed consent was signed. V12 stated the vaccine company will document on the informed consent form what vaccines are given. V12 stated the vaccinations are also documented under the immunization tab in the computer system. V12 reported R169's immunizations are documented as pending immunization either due to not receiving the vaccines yet or V12 has not entered them in the computer system. V12 stated V12 would have to check why R169 did not have documentation that vaccines were administered on the informed consent form or in the computer system. V12 denied knowing why R169 refused the vaccine in September but then requested them in December. On 2/6/25 at 2:22PM, V10 (DON) stated the facility holds vaccine clinics that are scheduled by either V10 or V12 as needed to ensure all residents are vaccinated if they desire. V10 was not able to answer why R169 had not been vaccinated yet. On 2/6/25 at 3:13PM, V12 confirmed that R169 has not been given the influenza or pneumonia vaccine after signing consent on 12/31/24. V12 denied R169 having any additional refusal forms other than the documentation on 9/13/24. On 2/6/24 at 3:24PM, R169 stated R169 was offered the flu and pneumonia vaccine by an unknown staff member in 09/2024. R169 reported not understanding what the vaccine was and what it was for due to R169 speaking Spanish. R169 denied any staff members explaining what the vaccines were for in Spanish so R169 refused the vaccines at that time. R169 stated R169 went to an appointment outside the facility in 12/2024 and asked the physician what the vaccines were for since the physician spoke Spanish. R169 reported the physician recommended R169 receive the vaccinations due to R169 co-morbidities. R169 stated R169 then requested to receive the vaccines upon return to the facility. R169 denied being given any education in English or Spanish about the vaccines. R169 reported R169 signed a form allowing the facility to give the vaccines, but R169 denied the facility administering the vaccines. (continued on next page) 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 02/07/2025 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 0883 Level of Harm - Minimal harm or potential for actual harm The Immunization tab in the computer system documents the flu and pneumonia vaccine as Pending Immunization. The Annual influenza Vaccine Consent Form and Pneumococcal Vaccine Consent Form dated 9/13/24 documents R169 refused both vaccines on this day. This form was given to R169 in English. Residents Affected - Few The Informed Consent for Immunization with Inactivated and Live Vaccines dated 12/31/24 documents R169 has given consent to receive the influenza and pneumonia vaccine. This form was again given to R169 in English. The box at the bottom of the page is blank indicating r169 has not received any vaccinations. The progress notes were reviewed from 09/2024 through present. There is no documentation that R169 was given the influenza or pneumonia vaccine or that R169 was provided education about the vaccines in Spanish. As of 2/6/25, R169 was still not vaccinated for influenza or pneumonia or educated. There is also no documentation that R169 was asked about receiving the vaccines other than on 9/13/24 when R169 initially refused. 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 02/07/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the COVID-19 vaccine and provide education in a language a resident understood. This affected one of five (R169) reviewed for Covid-19 vaccinations in a total sample of 55. Findings Include: R169 is a [AGE] year old with the following diagnosis: type 2 diabetes, end stage renal disease with dependence on hemodialysis, congestive heart failure, and peripheral vascular disease. The facility vaccination log was reviewed during the annual survey process. R169 was randomly selected to check compliance with vaccination status. On 2/6/25 at 12:34PM, V12 (Infection Prevention Nurse) stated the facility hold vaccinations clinics beginning in September and calls out the vaccine company as needed to make sure all residents are vaccinated. V12 was unable to provide the exact dates but reported the vaccine clinics have been held in 09/2024, 10/2024, and 01/31/2025. V12 stated R169 was first asked about the vaccines in 09/2024 and R169 refused the vaccines at that time. V12 reported residents are asked before every vaccine clinic to determine if the residents want the vaccine or still refuse. V12 stated R169 should have been asked before each clinic and there should be documentation R169 refused each time. V12 reported R169 requested to have the vaccines on 12/31/24 when the informed consent was signed. V12 stated the vaccine company will document on the informed consent form what vaccines are given. V12 stated the vaccinations are also documented under the immunization tab in the computer system. V12 reported R169's immunizations are documented as pending immunization either due to not receiving the vaccines yet or V12 has not entered them in the computer system. V12 stated V12 would have to check why R169 did not have documentation that vaccine was administered on the informed consent form or in the computer system. V12 denied knowing why R169 refused the vaccine in September but then requested them in December. On 2/6/25 at 2:22PM, V10 (DON) stated the facility holds vaccine clinics that are scheduled by either V10 or V12 as needed to ensure all residents are vaccinated if they desire. V10 was not able to answer why R169 had not been vaccinated yet. On 2/6/25 at 3:13PM, V12 confirmed that R169 has not been given the COVID-19 vaccine after signing consent on 12/31/24. V12 denied R169 having any additional refusal forms other than the documentation on 9/13/24. On 2/6/24 at 3:24PM, R169 stated R169 was offered the COVID-19 vaccine by an unknown staff member in 09/2024. R169 reported not understanding what the vaccine was and what it was for due to R169 speaking Spanish. R169 denied any staff members explaining what the vaccines were for in Spanish so R169 refused the vaccines at that time. R169 stated R169 went to an appointment outside the facility in 12/2024 and asked the physician what the vaccines were for since the physician spoke Spanish. R169 reported the physician recommended R169 receive the vaccinations due to R169 co-morbidities. R169 stated R169 then requested to receive the vaccines upon return to the facility. R169 denied being given any education in English or Spanish about the vaccines. R169 reported R169 signed a form allowing (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 02/07/2025 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 0887 the facility to give the vaccines, but R169 denied the facility administering the vaccines. Level of Harm - Minimal harm or potential for actual harm The Immunization tab in the computer system documents the flu and pneumonia vaccine as Pending Immunization. Residents Affected - Few The Annual influenza Vaccine Consent Form and Pneumococcal Vaccine Consent Form dated 9/13/24 documents R169 refused both vaccines on this day. This form was given to R169 in English. The Informed Consent for Immunization with Inactivated and Live Vaccines dated 12/31/24 documents R169 has given consent to receive the COVID-19 vaccine. This form was again given to R169 in English. The box at the bottom of the page is blank indicating R169 has not received any vaccinations. The progress notes were reviewed from 09/2024 through present. There is no documentation that R169 was given the COVID-19 vaccine or that R169 was provided education about the vaccine in Spanish. As of 2/6/25, R169 was still not vaccinated for COVID-19 or educated. There is also no documentation that R169 was asked about receiving the vaccines other than on 9/13/24 when R169 initially refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145718 If continuation sheet Page 14 of 14