Health inspection·December 19, 2024

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 adequately ensure a resident (R2) was free from abuse. This failure applied to two (R1, R2) of two residents reviewed for abuse. Findings include: R1 is a [AGE] year old male who originally admitted to the facility on [DATE] and later discharged on 11/23/2024. R1 has multiple diagnoses including but not limited to the following: schizoaffective disorder, bipolar disorder, psychoactive substance abuse, depression, psychosis, auditory hallucinations, and suicidal ideations. R2 is a [AGE] year old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: COPD, Alzheimer's disease, CAD, type II DM, osteoarthritis, depression, bipolar disorder, and anxiety. Per Minimum Data Set (MDS) dated [DATE], shows R2 has a brief interview of mental status (BIMS) of 14 meaning resident is cognitively intact. On 12/18/2025 at 10:47AM, R2 was interviewed regarding incident on 11/22/2024 with R1. R2 said I was in my room with R3 when R1 came to the doorway. R1 briefly left and later returned. R2 said this is the first time I've interacted with this resident. R2 said I went to the door to see what R1 wanted when he asked me for a hug. He leaned in, hugged me, and gave me a kiss on the cheek. R2 said this was something I did not want to happen, and I it was an inappropriate behavior. R3 witnessed this interaction and asked R1 to leave. I immediately told V5 (Certified Nursing Assistant) and V4 (Licensed Practical Nurse) what had happened. R2 said it caused me to feel a bit uneasy. During the course of this survey, V4 and V5 were both interviewed. Witness statements dated 11/25/24 from R2 and R3 were reviewed. It is to be noted that interviews and witness statements are consistent with interview from R2. On 12/18/2025 at 11:51AM, V1 (Administrator) was interviewed regarding incident with R1 and R2 on 11/22/2024. V1 said V4 notified me that R1 had come into the doorway of R2's room and kissed R2 on the cheek. I was told that R3 was a witness to the incident, therefore I interviewed R2 and R3. I was unable to interview R1 due to him being sent to the hospital and he did not return to the facility. (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 2 Event ID: 145866 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 145866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Vlg Nrsg & Rhb 9246 South Roberts Road Hickory Hills, IL 60457 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)