Inspection·February 7, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few how much mouthwash R1 drank if any. V5 stated that the nurse informed her to get R1 ready because R1 was getting sent out to hospital for psychiatric evaluation. V5 stated that another staff member assisted her in getting R1 dressed and then R1 left facility. On 2/3/25 at 11:00AM, V5 CNA stated that when V5 did morning rounds, R1's roommates were complaining that R1 was hollering all night. V5 stated that later the housekeeper went into R1's room to empty garbage, then told V5 he was soiled. V5 stated that she went into R1's room and found the empty bottle of mouthwash. V5 stated that it was a large bottle with a brown label on it. V5 stated that V5 brought the empty bottle to the nurses' station and gave it to V3. V5 stated that another staff member assisted V5 with providing incontinence care to R1. V5 stated that R1 typically does his care himself and is not incontinent. V5 stated that when R1 is not lucid he is very combative. V4 RN (Registered Nurse) stated that V4 worked 3-11PM shift on 1/12. V4 stated that R1 was gone before she arrived at work. V4 stated that one of his diagnoses is screaming out. V4 stated that when R1 exhibited this behavior before and R1 informed V4 that he was having a nightmare. V4 stated that R1's screaming/moaning was increased on 1/12 and that is reason they sent him out. V3 LPN (Licensed Practical Nurse) stated that V3 was working day shift on 1/12/25. V3 stated that R1 was yelling out, talking about stuff that did not make sense, and arguing with his roommates. V3 stated that R1 had a pushcart he used when walking. V3 stated that R1 put the cart in bed on top of him. V3 stated that V3 was able to remove cart from R1's bed and place it away from R1 so R1 would not put it back in bed. V3 stated that V3 exited R1's room and notified the psychiatric physician who gave an order to send R1 to the hospital for evaluation. V3 stated that V3 notified V2 and called the hospital to give verbal report. V3 stated that R1 was transported by an outside ambulance service. V3 stated that R1 had an independent community access pass. V3 stated that the residents' bags are searched upon returning from independent pass. V3 stated that residents go to the nurses' station to have their bags checked. On 2/3/25 at 10:00AM, V3 stated that she was in and out of R1's room because he was yelling all day. V3 denied seeing a bottle of mouthwash on 1/12. V3 stated that she is unsure time she last saw R1, but R1 was alert and oriented x 4 at that time. On 2/3/25 at 10:30AM, V6 (Social Services) stated that R1 did not have an independent pass to go out into the community. V6 stated that R1 was hospitalized a couple of times due to behaviors. V6 acknowledged that R1's care plan is correct and R1 was not able to go out on independent pass, R1 could go out on supervised pass with family, friends, or staff. V6 stated that with supervised pass, the person picking up the resident has to come into facility and sign resident out and then back in again upon returning. V6 was informed that this surveyor was given independent pass sign out sheets for R1 for December and January. V6 responded that R1 was able to go out on independent pass. V6 was unable to articulate how a resident would have a restricted community pass and an independent community pass at the same time. On 2/3/25 at 12:00PM, V8 (Nurse Practitioner) stated that anyone with alcohol abuse should not have access to alcohol or alcohol-based products. V8 stated that he is not sure how much mouthwash R1 drank on 1/12. R1's ambulance run sheet, dated 1/12/25, notes at 3:29PM a request for transport to the hospital for R1 due to behaviors was made by facility staff. The outside ambulance crew arrived at R1's bedside at 4:09PM. R1's nurse reported that R1 drank a full bottle of mouthwash and started to drink a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145866 If continuation sheet Page 2 of 7 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 02/07/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few second one before staff found R1. R1 is also reported to be alert and oriented x 4. The crew's assessment noted R1 to be alert and oriented x 1, skin cold, diaphoretic, mental status - slowed processing/response, confused, lungs with increased respiratory effort and breaths shallow. R1's hospital medical record, dated 1/12/25, notes when R1 presented to the emergency room, R1's respirations were very slow and sluggish and R1 was unresponsive. R1's pupils were poorly responsive. Oxygen saturation level 75% on room air. Narcan 2mg (milligrams) was administered sublingual and R1's breathing improving but still unresponsive. Narcan 2mg administered intravenously and R1 was intubated and placed on mechanical ventilator. Blood pressure gradually started to build up to 109/60 from 62/40. Arterial blood gas results showed severe metabolic acidosis. Poison control was contacted. R1's alcohol level was 183 (normal range is 0-10). The physician's narrative notes R1 is evaluated for drug overdose and respiratory difficulty including but not limited to mouthwash overdose. An urgent nephrology consultation was ordered for persistent severe metabolic acidosis and acute kidney failure. R1's laboratory results showed potassium level 6.1 (normal range is 3.5-5.1), creatinine (kidney function) level 4.21 (normal range is 0.6-1.2), and blood sugar level 41 (normal range 70-99). R1's death certificate, dated 1/13/25, notes cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. R1's community pass sign out sheets were provided by V1 (Administrator).They are dated 12/9/24 - 12/15, 12/27 - 12/30, and 1/2/25 - 1/13. These sheets document that R1 went out on independent passes 12/9, 12/10, 12/13, 12/30, and 1/3. R1's POS (physician order sheet), dated 1/12/25 at 12:41PM, notes an order to transfer R1 to the hospital for a psychiatric evaluation. R1's involuntary petition for hospitalization, dated 1/12/25 at 1:04PM, notes R1 was seen drinking mouthwash, staring off, and staring at wall. R1's substance use/abuse care plan, dated 9/4/24, notes R1 has a history of alcohol and illegal drug abuse. R1's community access observation, dated 11/27/24, notes R1 with history of public intoxication. R1 may not access the community independently related to safety factor. R1's community access care plan, dated 9/4/24, notes R1 may not access the community independently due to physical function and therapy goals. R1 may access the community with supervision. R1's mouthwash was identified as an original mouthwash with 26.9% alcohol by volume (the equivalent of 54 proof alcohol). It also contains eucalyptol, menthol, methyl salicylate, and thymol. The National library of medicine, dated 11/2/2023, notes poisonous ingredients in mouthwash that can be harmful in large amounts are: alcohol and methyl salicylate. Symptoms of mouthwash overdose include, but not limited to drowsiness, low body temperature, low blood pressure, low blood sugar, rapid heart rate, and rapid shallow breathing, slowed breathing, unconsciousness, and unresponsive reflexes. Per the National Library of Medicine, nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145866 If continuation sheet Page 3 of 7 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 02/07/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in the toxic range of these ingredients. The phenolic compounds in mouthwash may contribute to severe metabolic acidosis, multiorgan system failure, and death. These compounds in addition to alcohol may account for the adverse effects associated with massive mouthwash ingestion. This facility's community pass policy, undated, notes approving or denying resident's independent community access or supervised community access related to, but not limited to identified risk factors in-which would place a resident in jeopardy of abuse, neglect, dehydration and any physical or psychological harm. If a resident exits the facility independently without a pass it will be assessed or evaluated to be determined whether it's an elopement, unauthorized departure, or against medical advice due to the presented risk factors. Level 1 pass privilege: resident can only access the community if he/she is accompanied by staff, family member, friend, and/or responsible party. Responsible party to inform staff the duration of pass. This facility's prohibited items policy, undated, notes residents are prohibited from possessing or having in their room any item that may pose a threat to the safety of residents. The list includes, but not limited to alcohol and potentially poisonous chemicals. The Immediate Jeopardy that began on 1/12/25 was removed on 2/4/25 when the facility took the following actions to remove the immediacy. 1. Ambulance was contacted for R1 nonemergent transfer to the hospital for behaviors. R1 was evaluated at the emergency room. 2. Facility identified residents who are at risk for obtaining contraband. This was determined by diagnosis of history of substance abuse. Independent passes were reviewed. Current substance abuse was assessed. For residents who are at risk for obtaining contraband, facility interventions include: a. Residents were interviewed and asked if they were in possession of any contraband. All residents interviewed denied having any contraband. b. Residents consented for room search with resident present and no contraband was identified. c. Residents have been offered counseling with facility counselor. d. Facility will conduct random checks with resident present to ensure no contraband is in room. Random checks will be completed once per week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145866 If continuation sheet Page 4 of 7 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 02/07/2025 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)

F 0689 e. Level of Harm - Immediate jeopardy to resident health or safety Staff will check residents' bags upon return from out on pass to ensure no contraband is in bags. Any items identified as contraband will be removed from bags and placed in social service office. f. Residents Affected - Few Alcohol based mouthwash will be considered contraband for residents with a substance abuse diagnosis. 3. Starting 2/4/2025 at 1pm, DON and Administrator will educate staff including staff on leave and on vacation on facility's prohibited (contraband) items. a. Staff will complete test to gauge understanding of teachings. 4. Starting 2/4/2025 at 1pm, All facility staff including staff on leave and on vacation will be educated and trained on signs and symptoms of alcohol intoxication and alcohol poisoning. a. Staff will complete test to gauge understanding of teachings. 5. Starting 2/4/2025 at 1pm, DON will in-service all nurses including nurses on leave and on vacation on Change of Condition Policy. a. Staff will complete test to gauge understanding of teachings. 6. Residents who have an independent pass and DX of substance abuse will be re-assessed for Community Pass. Started on 2/4/25 at 12pm and Completed by Social Service Director on 2/4/2025. 7. Residents who go out on pass supervised or independent will be subject to a of search bags that were brought in. a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145866 If continuation sheet Page 5 of 7 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 02/07/2025 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)

F 0689 Prohibited items will be removed immediately and kept at social service office. Level of Harm - Immediate jeopardy to resident health or safety b. Residents Affected - Few c. Staff will inventory bags brought in from community. Designee will review items that were brought in the next day for compliance. 8. Starting 2/4/2025 at 1pm, Social service will provide list of residents who are on Community Pass Restriction to Nurses to communicate any updates to ensure residents who are on restriction do not leave for independent pass. a. Nurses will be in-serviced on process. Starting 2/4/2025 at 1pm. b. It is not a new procedure to notify nurses of resident's pass privilege. Community Pass Policy Updated to reflect notification to nurses of resident's pass privilege. c. Community Pass Privilege or Restriction of Community Pass will be documented in the resident's physician orders. Community Pass Policy updated to reflect documentation in physician orders of pass status. 9. Facility held resident counsel to discuss facility's prohibited and contraband items. All residents attended. Completed 2/4/2025. a. Residents will complete test to gauge resident's understanding of teachings. 10. Facility will place the list of prohibited items at the back entrance to inform family and visitors. 11. Medical Director made aware of IJ on 2/4/2025 at 12pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145866 If continuation sheet Page 6 of 7 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 02/07/2025 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)

F 0689 12. Level of Harm - Immediate jeopardy to resident health or safety Administrator coordinator or designee will conduct QA studies: Residents Affected - Few A QA study will be performed at random weekly to ensure residents who are at risk of obtaining contraband do not have prohibited items in room. The QA will be completed weekly for 3 months. a. b. A QA study will be performed random twice weekly to ensure staff knowledge of signs and symptoms of alcohol intoxication and alcohol poisoning. The QA will include 5 staff members twice weekly for 3 months. c. A QA study will be performed random twice weekly to ensure residents do not bring in prohibited items from the community. The QA will include 5 residents twice weekly for 3 months. d. A QA study will be performed random twice weekly to ensure that a physician order reflecting residents community pass privilege is up to date, reviewing community pass logs to ensure residents sign in and out from pass, and to ensure nurses are aware on who is restricted from community pass. e. QA audits will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 13. An emergency QAPI was conducted on 2-4-2025 at 11am. 14. Date of Completion: 2/4/2025 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145866 If continuation sheet Page 7 of 7