Health inspection·May 12, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents do not have access to alcohol and other illicit drugs while at the facility. This failure affected one resident (R1) and has the potential to affect four other residents (R2, R5, R6, and R11) reviewed for adequate supervision and access so alcohol/illicit drugs at the facility. As a result, R1 got drunk and consented to sexual activity that she claimed happened while under the influence of alcohol and illicit drugs. R1 reported that the sexual activity caused emotional harm to her(R1) and R1 was sent to the hospital. Findings include: R1's records show the following: Progress notes dated 4/25/25 at 11:00pm written by V7(RN/Registered Nurse) states in part that R1 was suspected to be intoxicated. V7 notified the Nurse Practitioner who gave an order to hold all R1's medications for the night. Progress notes dated 4/28/25 at 6:35pm written by V3(Social Services Director) states in part that R1 was tested for drugs because R1 admitted to using drugs recently. Test results showed that R1 had cocaine and marijuana in her system. On 5/1/25 at 12:05pm, R1 stated (R2) is a friend. He's nice and respectful. We smoke and drink together. On this Friday night, we were drinking and I got very drunk and went to my room to lay down. In the middle of the night, I felt somebody penetrated me; I felt there was a chain on the neck of the person. The next day when I woke up at 5am, I was naked. I did not give consent to have sex with anyone. When I asked the nurse, the nurse told me that I was intoxicated and throwing things around in my room. So, I did not tell her that I thought someone raped me. So, on Monday, I told the staff that supervise us during smoking, and also told the nurse (V5/LPN/Licensed Practical Nurse). So, they called the ambulance, but I went to my sister's house on a pass and told my sister. My sister called here and spoke with the nurse, and the nurse told me to come back to the facility. I returned about 3pm when my pass was over. I was sent to the hospital and did all the tests and came back here. Inquired from R1 if R1 had been drinking and smoking anything outside of the official smoking time that is supervised by staff. R1 responded that she(R1) and other residents usually drink and smoke pot (Marijuana) together. On 5/1/25 at 11:45am, R2(male resident/alleged sexual abuser) stated I was chilling and (R1) came into my room around 10:00PM. She and I were getting intimate together in my room. We then went into the bathroom and smoked a blunt and she gave me oral sex. It was just the two of us in the bathroom. Page 1 of 5 145995 145995 05/12/2025 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0689 Level of Harm - Actual harm Residents Affected - Few After she gave me oral sex, she went to her room. She came back down to my room and told me that her roommate was asleep so we could have sex in her room. After we smoked a blunt, we had sex. I left her room and went back to my room. We both agreed to the oral sex and intercourse. I texted her thank you and she sent me a heart emoji. R2 added that R1 was her normal self and was cracking jokes and chilling before and after the intercourse. R2 stated that R1 told him not to tell anyone that they had sex because she has a boyfriend. R2 stated that R1 did not appear intoxicated or impaired to him, and she(R1) put herself into bed and the sex was not aggressive. R2 stated that this was not the first time, and it was consensual. On 5/7/25 at 9:16 am, V7(RN) was interviewed and stated I was the nurse on the unit that Friday night. I saw (R1) in her bed when I did my rounds. I saw some of her things like water bottle and plate on the floor. I did not see her go into anybody's room and I did not see anybody go into her room. She did not report anything to me. But when I came to work on Monday evening, and I heard about what happened, I was surprised. I was the nurse for Friday night and Saturday night, and I was surprised that all throughout my 12 hours shift on Friday and Saturday, she(R1) did not tell me anything unusual happened. On 5/7/25 at 10:41am, V8 (CNA/Certified Nurse Assistant) stated I was the aide on that unit for the night. I made rounds to check everyone up to 4 times, and each time, I saw her(R1) in her bed. The last time I made my rounds, she(R1) asked me for water, and I went to get her water. I did not see anyone go into her room, and I did not see her go into anybody's room. I did not hear any screaming or yelling or nothing. It's my first time of working on that unit. On 5/5/25 at 2:00pm, V12(Receptionist/Director of Admissions) was interviewed about how some residents were able to bring alcohol/drugs into the building. V12 stated We check their bags but not their person. If anyone brings in drug or alcohol, we let them have a seat in the lobby and call social services staff so take it from there. On 5/8/25 at 2:25pm, V11(R1's Physician/Medical Director) was interviewed about residents getting access to alcohol/drugs and becoming intoxicated and the possible effects on the residents. V11 stated They notified me about the situation, and I spoke with (R1). (R1) told me that she got the alcohol from outside. I suggested that the facility puts her on Pass Restriction, and anyone else who comes back to the facility with alcohol or is intoxicated. V11 added Alcohol intake will increase the sedation for anyone on pain medication, and there are other side effects on other medications the patient is taking. I'm concerned about this situation just like you're concerned. I'm glad you called me, and they(facility) are working on making sure the patients don't have access to alcohol or drugs. R1's other records: Care Plan dated 5/1/25 states in part that resident has a substance abuse and chemical dependency issue with marijuana. Face sheet shows diagnoses which include but are not limited to Major Depressive Disorder, And Generalized Anxiety Disorder. BIMS (Basic Interview for mental status) score dated 2/28/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from 145995 Page 2 of 5 145995 05/12/2025 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0689 alcohol and illicit drugs. Level of Harm - Actual harm R2's Records reviewed are as follows: Residents Affected - Few Care Plan dated 5/1/25 states in part: The resident has a history of substance abuse/chemical dependency related to: Clinical depression & anger (substance abuse often indicates an attempt at self-medicating). Face sheet shows diagnoses which include but are not limited to Depression and Bipolar Disorder. BIMS score dated 3/14/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] and 3/25/25 states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. R5's Records reviewed are as follows: Face sheet shows that R5 was originally admitted to the facility on [DATE] with diagnoses which include but are not limited to Cirrhosis of The Liver, Chronic Viral Hepatitis C, Alcohol Dependence with Withdrawal, and Generalized Anxiety Disorder. Progress notes/History of Present Illness dated 5/1/25 written by V11(Medical Director/Physician) states that R5 (with a diagnosis of Alcohol Liver Disease) was sent to and admitted to the outside hospital for alcohol withdrawal/abuse and has Cirrhosis of the Liver. This note also states that patient was medically stabilized and discharged to this facility to continue sub-acute care with skilled nursing and medical supervision. Progress Notes dated 4/24/25 states that R5 was taking a medication called Acamprosate Calcium 666 mg(milligrams) every 8 hours related so alcohol dependence with withdrawal. Care Plan dated 11/29/24 states in part: The resident has a history of substance abuse/chemical dependency related to: Clinical depression & anger (substance abuse often indicates an attempt at self-medicating). BIMS (Basic Interview for mental status) score dated 4/9/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] and 3/13/25 states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. However, records show that resident has access to Alcohol and drinks alcohol. R6's Records reviewed are as follows: Care Plan dated 10/22/24 states in part: Resident has a history of substance abuse/chemical dependency related to: Poorly developed ability to control impulses., Allowing negative, inappropriate persons to influence his/her use of substances. Face sheet shows diagnoses which include but are not limited to Alcohol Use, Cocaine Use, Schizoaffective Disorder, Bipolar Disorder, and Generalized Anxiety Disorder. 145995 Page 3 of 5 145995 05/12/2025 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0689 BIMS score dated 4/15/25 shows 15(Cognitively Intact). Level of Harm - Actual harm Community Survival Skills assessment dated [DATE] states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. However, records show that resident has access to Alcohol and drinks alcohol. Residents Affected - Few R11's Records reviewed are as follows: Progress notes dated 5/1/25 at 5:47pm written by V10(LPN) states in part: Writer was informed that resident was being aggressive to staff members and under the influence by social services. Patient is being sent to the Hospital. Face sheet shows diagnoses which include but are not limited to Opioid Abuse, Cocaine Abuse, Major Depressive Disorder, And Fatty Liver. Community Survival Skills assessment dated [DATE] and 3/13/25 states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. Care Plan dated 11/26/24 states in part that how R11 has a history of substance abuse and chemical dependency with marijuana. On 5/5/25 at 12:38pm, V1(Administrator) was notified about the concern that some residents at the facility have access to alcohol and some residents occasionally get intoxicated. V1 responded that staff can only search residents' bags and not the person. V1 added that now, if a resident is found with alcohol, or drugs, we would take their pass away. Also, we have a certified alcohol dependence counselor that comes five days a week. This will help the residents. V1 explained that all the residents that are known to have drank alcohol or have unauthorized access to alcohol or drugs have been documents to sign (Resident Coduct and Behavior Contract) with the House Rules and the resident who refused to consent to obeying the rules (R5) left the facility against medical advice (AMA). V1 stated that the issue of residents having access to alcohol or drugs is now under control because some residents' passes have been restricted. Facility's Policy on Contraband Materials, Inspection of Rooms, and Use of Recording Devices states in part: This organization follows federal standards concerning removal of contraband. This policy includes but are not limited to alcohol, illicit drugs, weapons, and smoking materials. #5 states: This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past. If this appears to be the case and staff assesses and suspects that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed. #7 states: The Facility may choose, at its discretion, to involve sniffing dogs if residents are suspected to be trafficking drugs inside the facility. Facility's document titled Resident Smoking Conduct, and Behavior Contract states in #3: Refrain from refrain from any type of substance abuse in the facility and while in the community while out on pass. #5 states: Refrain from bringing contraband into the facility including but not limited to alcohol, marijuana, heroin, cocaine, vape pens, illegal substances, and any sharp or dangerous objects. Facility's Policy 9/2021 with latest revision 11/2024 states in part: Our facility strives to make 145995 Page 4 of 5 145995 05/12/2025 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0689 Level of Harm - Actual harm the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. #1 states in part: Our facility-oriented approach to safety addresses risks for groups of residents. Residents Affected - Few 145995 Page 5 of 5