Health inspection·February 28, 2025

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few Based on interviews and record reviews, the facility failed to follow its change in resident's condition policy and its urgent laboratory testing protocol and notify the attending physician/nurse practitioner the urgent laboratory tests ordered were not done within the 4-6-hour time frame. This affects one of three residents (R1) reviewed for notification of physician of changes in condition. This failure resulted in over a nine-hour delay of labs being obtained. R1 was subsequently sent to the local hospital. R1 was admitted and treated for the diagnosis of dehydration, pneumonia, and urinary tract infection. Findings include: On 2/27/25 at 10:07AM, V5 RN (registered nurse) stated that V5 is familiar with R1. V5 stated that V5 sent R1 to the hospital on 1/19 for pneumonia. Stated that R1's family member took R1 home for a couple of days. V5 stated that shortly thereafter R1 got sick. V5 stated that urgent laboratory tests should be done within 4-6 hours, if not done within that time, the nurse is expected to call the primary physician/primary nurse practitioner and ask want he/she wants to do; wait or send resident out to hospital. V5 stated that the nurse is expected to document in the resident's progress notes urgent orders and if not done within time frame document physician notification and any follow up orders. V5 stated that the nurse also documents on 24 report sheet that laboratory tests are pending. V5 stated that R1's eating had decreased and R1 was weak. V5 stated that V5 would assist R1 with eating. On 2/27/25 at 12:20PM, V6 CNA (certified nurse aide) stated that V6 is familiar with R1. V6 stated that R1 started eating and drinking less mid January when R1 became sick. V6 stated that the CNAs are expected to document the amount eaten and fluids in POC (point of care) charting. V6 stated that the CNAs are expected to report if the resident has decreased intake or refusal to eat to the nurse. V6 stated that when R1 started to get sick, R1 stopped getting out of bed. V6 stated that R1 was more tired and weak, coughing and looked dehydrated; R1 just looked sick. V6 stated that R1 started becoming incontinent of bowel and bladder, staff had to feed him. The facility's staffing assignment sheets note V6 provided care for R1 on the day shift on 1/12, 1/14, 1/16, and 1/17. On 1/17 V6 also provided care for R1 on the evening shift. On 2/27/25 at 2:05PM, V8 (primary NP) stated that when V8 orders testing to be done, V8 expects it to be done. V8 stated that when V8 was informed of R1's BMP results, R1 was really dehydrated. V8 stated that V8 ordered intravenous fluids for R1. V8 stated that when V8 was notified that V5 nor the outside midline catheter insertion nurse could not access a vein, V8 knew R1 was severely dehydrated. V8 stated that at a critical time V8 did not know what was going on with R1 because the nurses (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145718 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 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)