Health inspection·March 21, 2025

F 0568 Level of Harm - Minimal harm or potential for actual harm Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on interview and record review the facility failed to follow their policy and maintain an accurate account of the resident personal funds for one of three residents (R14) reviewed for resident funds. Residents Affected - Few Findings include: On 3/18/25 at 11:12am R14 said he only receives 30 dollars a month, R14 said he's not sure of his trust fund statement, R14 said he's not sure about his account balance. On 3/20/25 at 10:36pm V22 (Business Office Manager) said R14 has a resident trust fund account. V22 presents documentation denoting R14 has 1510.13 dollars in his resident trust fund account, print date 3/20/25. V22 said the 1510.13 is R14's total balance. During a follow up interview V22 said R14 only has 754.00 dollars in his trust fund account. V22 said she has not been keeping an accurate account of R14's resident trust fund. Facility policy titled RESIDENT PERSONAL TRUST FUNDS dated 4/2024 denotes in-part, purpose: It is the practice of this facility to hold, safeguard, manage and account for personal funds if any resident requests facility to establish personal funds account in their behalf and deposits money with the facility in an interest-bearing account. Specifications: To establish guidelines and maintain a system for protecting resident funds which assures a full and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. Responsible Party: Administrator, Business Office Manager and Social Service Director. Resident personal funds will be maintained in the Business Office. Accounts and records will be maintained in accordance with the American Institute of Certified Public Accountants' generally accepted accounting principles. 10. The Business Office Manager will make arrangements for an interest-bearing account which will be used for the sole purpose of resident personal funds and will ensure that such accounts remain separate from any facility operating accounts. Interest shall be allocated to each resident's account at the end of each month in proportion to the resident's closing balance for that month. 11. The Business Office Manager will audit the Trust Fund account /cash and balance the personal funds bank account monthly. Upon the exit of this survey the facility failed to provide documentation of the accurate account for R14 resident trust fund. 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 03/21/2025 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)