Health inspection·June 17, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a clean, sanitary environment in the facility's common areas. These failures affect all 69 residents that reside within the facility. Findings include: Resident Roster (6/16/25) documents in part that 69 residents reside within the facility. R2's Minimum Data Set (MDS) dated [DATE], documents in part a brief interview of mental status (BIMS) summary score of 13, indicating R2 is cognitively intact. On 6/16/25 at 9:31 AM, R2 stated that the facility is never cleaned or repaired, just look around this place. It makes me feel bad, like I am in a prison. You can tell they don't care about me or the other people. On 6/16/25 at 10:09 AM, a facility tour was conducted with V1 (Administrator) and the following observations were affirmed with V1: dirt-stained floors within dining room, dirt stained floors within the hallways, dried brown substances dripping on the walls underneath the bulletin board in main hallway, dried yellow stain from an unidentified yellow liquid throughout the entrance to the gentleman's restroom, dried red stain with approximately 3 feet in diameter from an unidentified red liquid in the group room. V1 stated that, the floors (of the facility) have definitely seen better days. V1 explained that floors and common areas should be cleaned daily and was unable to identify the substances that caused the stains. On 6/17/2025 at 9:40 AM, bathroom [ROOM NUMBER]'s toilet bowl was covered with a brown substance, brown substance was dried and smeared on the toilet seat, and an odor of feces was observed coming from the room. V10 (Activity Aide) observed the bathroom and affirmed that the brown substance was fecal matter and that the bathroom needed to be cleaned. On 6/17/2025 at 9:45 AM, the same approximately 3-foot red stain was observed within the group room. 2 additional approximately 1.5-foot splattered, dried red stains were observed under 2 other tables within the group room, as well as a 1-foot dried brown stain under another table on top of one of the red stains. Surveyor began to walk towards the table nearest to the activity director's desk and the surveyor's shoes began to stick to the ground. No wet substances were noted where the surveyor walked. V10 affirmed that the surveyor's shoes could be heard sticking to the ground and observed the dried stains under the table. V10 did not know how long the stains had been present for. V9 (Activity Director) stated that V9 thought the stains were possibly from the cranberry juice that is (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 06/17/2025 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)