Health inspection·July 3, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 07/01/25, at 11:36 AM, V16 (Housekeeper) stated she prioritizes cleaning the dining room first, then the nursing station, the employee bathroom and she starts cleaning the resident rooms. She eventually works her way toward the shower room. V16 stated she cleaned the shower room yesterday and it looks this dirty every day. V16 viewed the black spots on the ceiling tile above the shower stall and the black material in the grout on the walls of the shower stall and said, I don't know if that is mildew or mold but if it is mold it could make you sick by breathing that stuff in. V16 stated she always wipes down the tile walls but the black material on the grout does not wipe off. V16 observed hanging plastic shower curtain in the shower stall with areas of light brown material stuck it and said, that looks like feces. V16 stated she noticed the metal pole was not attached to the wall but did not say anything about it because she thought the Maintenance Director was doing his own monitoring and that is the type of thing he can and should fix. On 07/01/25, at 11:46 AM, V8 (Housekeeping Director) observed the condition of the shower room. V8 said, it does not look clean in here. V8 stated it looks like some type of material is growing on the ceiling tiles over the shower stall used by the residents and that the black stuff on the grout looks like mold. As surveyor was talking to V8, V8 was swatting away small flying black insects from her face. On 07/01/25, at 11:55 AM, V17 (Maintenance Director) stated he does walk throughs of the unit and talks to the residents and staff to see if there are any problems or if anything needs to be fixed. V17 stated no one told him there were any problems in the shower room so he did not know anything needed to be fixed. V17 stated he needs to make sure things are safe for the residents. V17 observed the dangling pole with the shower head attached to it and stated that the pole should be securely attached to the wall on both ends. As V17 was talking to the surveyor he was swatting small black flies away from his face using his hand/arms. V17 stated those black flies are gnats and they can come from the drains, and they are attracted to water and food. V17 stated the maintenance department treats the drains once a month and he did this 2 weeks ago. V17 observed the ceiling tiles and stated that looks like dust. V17 observed the grout and shower curtain and stated that should not be there and should be cleaned by the housekeeping staff. V17 observed the solid material on the floor next to the toilet bowl and stated, it could be feces. On 07/01/25, at 12:10 PM, R9's garbage can in his room was overflowing with garbage containing empty food containers, plastic drink bottles and tissues/paper. R9 stated that garbage has been there for two to three days. R9 stated his room had not been cleaned since Saturday, 06/28/25. R9 stated he likes to keep his room as clean as possible and wished his room could be cleaned more often, at least every couple of days. R9 said, getting it cleaned daily would be great! R9 stated none of the housekeepers asked him on Sunday or Monday if he wanted his room cleaned. R9 stated if they had he would have told them yes because he likes keeping his room clean and does not like it when the garbage piles up. R9 stated, I don't want to get flies in my room. R9 stated he uses the shower room to take showers because he has to use a shower chair when he showers. R9 stated the shower room is dirty and he has found dirty diapers on the floor, poop on the shower chair and wet/used towels on the floor. On 07/01/25, at 12:25 PM, R10 stated he has a garbage can in his room that is covered with a swinging lid top and inside the garbage can it is full of fruit flies. R10 stated the gnats or fruit flies must be attracted to the food inside of it. R10 is not sure how often his garbage can is emptied but he does not think it is done every day. On 07/01/25, at 12:39 PM, R10 brings surveyor to R10's room. Surveyor observed tall plastic garbage can near the entrance of R10's room with a swing top lid on it. The swing top lid was in the closed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145995 If continuation sheet Page 2 of 6 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 145995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632 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 0921 Level of Harm - Minimal harm or potential for actual harm position. R10 said, watch this and then quickly took his hand and tapped the top of the swing lid on the garbage can and a swarm of small black winged flying insects erupted from the rim of the garbage can flying around as R10 tried to swat them away. Some of them landed and settled on the wall of R10's room and on the outside of the garbage can. R10 said, see what I mean? R10 stated again he's not sure when the last time the garbage can was emptied. Residents Affected - Many On 07/01/25, at 12:44 PM, V18 (Certified Nursing Assistant) entered R10's room and observed all the tiny black flying insects hovering around R10's garbage can and along the wall in R10's room. V18 said, those are fruit flies or gnats, and they are unsanitary. V18 stated they are attracted to the food inside the garbage can. V18 stated housekeeping should be emptying the garbage cans in the residents' rooms every day. V18 stated she does not know if the garbage cans were emptied yesterday but based on the amount of garbage in that garbage can it does not look like it has been emptied in a while. V18 stated the facility wants to provide a clean and homelike environment for the residents to live in and no one wants flies like that in their home and they should not be in there. On 07/01/25, survey team observed that the 4th floor dining room floor was sticky and could see food particles and debris on the floor. On 07/02/25, at 10:23 AM, observed garbage in R2's bathroom to still be half full and still contain what appears to be the same can of soda seen on 07/01/25. R2 stated see? That is the same can of soda I put in there over the weekend. Why hasn't this garbage been emptied yet? On 07/02/25, at 10:27 AM, V16 (Housekeeper) stated yesterday she got pulled off the floor to treat the grout in the shower stalls to remove the mold that was there and that because of that she was not able clean the rooms at R2's end of the hall. V16 stated that is why she started at this end of the hallway this morning since those rooms were not cleaned yesterday. On 07/02/25, at 10:31 AM, during unit walk through observed tiny black flying insects in the hallway on the 3rd floor. On 07/02/25, at 10:40 AM, observed in the 1st floor shower room that the hand shower nozzle attached to a hose was dangling by the hose along the wall from the water outlet and was not mounted on anything. There was no poll to mount it on. Observed plastic pieces that appeared where an old pole may have been. Also, observed a showed bed with a full-length drain pan underneath the sling attached to the shower bed. In the full-length drain pan there was a large amount of murky brown tinted liquid with brown solid particles floating in the liquid and there was a foul odor coming from the liquid. Also, observed tiny black flying insects in the shower room area. On 07/02/25, at 10:45 AM, V22 (Certified Nursing Assistant) observed the condition of the 1st floor shower room. V22 stated because the detachable shower head does not have anything to be attached to on the wall, the resident using the shower would need to turn on the water and use the detachable shower head to wet their body first, then let go of the shower head to wash their body with soap and then pick the shower head back up to wash the soap off of themselves and then put the shower head back down again while they lather up their hair with shampoo and then pick the shower head back up when they want to rinse the shampoo out. V22 stated this means there is no way the residents can be covered by constant running water the entire time they are in the shower because they need their hands free to give themselves a shower properly. V22 stated she reported the problem directly to someone in maintenance to make them aware that it needed to be fixed. V22 observed the brown stained liquid with solid particles floating in the liquid pooling in the sling of the shower bed. V22 said, that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145995 If continuation sheet Page 3 of 6 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 145995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many could be feces. V22 stated that shower bed is used when giving R11 a shower. V22 stated she does not know who is supposed to clean that, but it needs to be cleaned, it should not have been left like that. V22 stated that has been like that for approximately one week. On 07/02/25, at 10:51 AM, V23 (Maintenance Assistant) observed the handheld shower nozzle attached to a hose dangling in the shower stall, not attached to anything. V23 stated this problem was not reported to him. V23 stated there should be a poll mounted on the wall so that the handheld shower nozzle can be attached to it so the residents can adjust to the height comfortable for them and so they can have continuous water on them while they are taking a shower, so they do not get cold. V23 observed liquid material in the shower bed under the sling in the drain pan and said, that doesn't look clean. On 07/02/25, at 11:01 AM, V25 (Housekeeper) stated she cleans the shower room every day as part of her daily responsibilities. V25 stated in the shower room she cleans the toilet, sink, shower head and stalls, sweeps/mops the floor and empties all the garbage containers. V25 observed the liquid material in the shower bed under the sling in the drain pan and stated, I don't clean that. When the CNAs give a shower, they are supposed to clean up afterwards. V25 stated that does not look clean and should not be left there. I can see brown liquid with stuff floating around in the liquid. On 07/02/25, at 1:30 PM, surveyor went to wash hands in the basement staff bathroom and when surveyor turned on the water tiny flying black insects flew out of the drain into the air. On 07/02/25, at 1:45 PM, V2 (Director of Nursing) stated he wants the facility to be free from accidental hazards to always keep the residents safe and all equipment should be in good working order. V2 stated the facility should be clean because this is where the residents live. V2 stated the residents have the right to live in a place free of garbage, debris, feces, dirty floors, garbage and free from pest/insects. V2 stated there should be no fruit flies or gnats in the facility because it is not sanitary. V2 said, I don't see them in my home, and I don't want them in here. On 07/02/25, at 2:51 PM, V17 (Maintenance Director) stated all equipment should be in working order to make sure the residents are safe and comfortable here. V17 stated it is everyone's responsibility to report any problems to the maintenance department. V17 stated he was not aware that the shower rails or shower head holder needed to be fixed or that it was broken and needed to be replaced. V17 stated if he had known that was a problem he would have fixed those areas right away. V17 stated he was not aware that there was a gnat problem, otherwise he would have called the pest control company immediately. V17 stated gnats are not going to go away on their own, they need to be treated and kill because otherwise they will continue to multiply. On 07/02/25, at 2:09 PM, V1 (Administrator) stated the facility wants to provide a clean, safe, and homelike environment for their residents. V1 stated it is important for the resident's well-being, infection control and safety. V1 stated the facility should be free from environmental hazards to keep the residents and the staff safe. V1 stated the purpose our pest control policy is to identify any pest problem and treat for pests to prevent the spread of them. V1 stated pests include insects like gnats and fruit flies. V1 stated pests/insects will not go away on their own and if the staff are seeing pests in the buildings, then they should be reporting that so the pest control company can treat for that. V1 stated the shower room drain should not be covered in hair or have any black/moldlike substance because that is unsanitary, there should be no feces like material on the floor or on the shower curtains or in the shower bed, and shower parts should be in good working order for resident comfort and safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145995 If continuation sheet Page 4 of 6 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 145995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R2 has a diagnosis including but not limited to Hepatic Encephalopathy, Other Cervical Disc Degeneration, Cervicothoracic Region, Generalized Anxiety Disorder, Esophageal Varices Without Bleeding, Repeated Falls, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region, Type 2 Diabetes Mellitus Without Complications, Insomnia, Major Depressive Disorder, Recurrent, Primary Insomnia, Alcohol Use, In Remission. R2's Brief Mental Status Interview (BIMS) dated 06/04/25 documents score of 15/15 indicating intact cognition. R9 has a diagnosis including but not limited to Paraplegia, Unspecified, Other Specified Diabetes Mellitus Without Complications, Age-Related Nuclear Cataract, Bilateral, Regular Astigmatism, Left Eye, Nicotine Dependence, Unspecified, With Unspecified Nicotine-Induced Disorders, Opioid Use, Uncomplicated, Bipolar Disorder, Generalized Anxiety Disorder, Primary Insomnia, Weakness, Opioid Abuse, Other Psychoactive Substance Use, Unspecified With Psychoactive Substance-Induced Sleep Disorder, Polyneuropathy, Bipolar Disorder, Current Episode Manic Without Psychotic Features, Moderate, Attention-Deficit Hyperactivity Disorder, Other Type, Suicidal Ideations, Anxiety Disorder, Insomnia, Tachycardia, Major Depressive Disorder. R9's BIMS dated 04/30/25 indicates intact cognition. R10 has a diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified, Unspecified Chronic Bronchitis, Other Asthma, Bronchitis, Not Specified As Acute Or Chronic, Hypoxemia, Hypertensive Heart Disease With Heart Failure, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Non-St Elevation Myocardial Infarction, Essential (Primary) Hypertension, Peripheral Vascular Disease, Alcohol Dependence, In Remission, Generalized Anxiety Disorder, Mixed Hyperlipidemia, Alcoholic Polyneuropathy, Major Depressive Disorder, Weakness. R10's BIMS score dated 05/01/25 indicates intact cognition. R11 has a diagnosis including but not limited to Muscle Wasting And Atrophy, Not Elsewhere Classified, Multiple Sites, Unspecified Protein-Calorie Malnutrition, Age-Related Nuclear Cataract, Bilateral, Limitation Of Activities Due To Disability, Need For Assistance With Personal Care, Difficulty In Walking, Other Lack Of Coordination, Cutaneous Abscess Of Right Axilla, Hidradenitis Suppurativa, Muscle Weakness (Generalized), Nutritional Anemia, Unspecified, Essential (Primary) Hypertension, Unspecified Osteoarthritis. R11's BIMS score dated 05/05/25 indicates intact cognition. R11's MDS (Minimum Data Set) dated 05/05/25 indicates R11 is dependent on staff for all ADL and mobility and is always incontinent of urine/bowel. Facility provided document titled, Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities dated 11/2018 which documents in part, your facility must be safe, clean, comfortable, and homelike. Facility provided document titled, Housekeeping Guidelines dated 07/2021 which documents in part, the purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors and housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner and pest control services will be monitored by the housekeeping personnel and shall report any problems or needs concerning pest control to the Administrator and contact will be made to outside service. Facility provided job description titled Housekeeping Assistant dated 07/2024 documents in part the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145995 If continuation sheet Page 5 of 6 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 145995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many primary purpose of this job is to perform the day-to-day activities of the Housekeeping Department at accordance with current federal, state, and local standards, guidelines, and regulations governing the facility, and as may be directed by the Administrator and or the Director of Housekeeping, to assure that the facility is maintained in a clean, safe, and comfortable manner. Facility provided document titled, Preventative Maintenance Program dated 11/2023 which documents in part, purpose is to conduct environmental/safety audits to identify areas of concern within the facility and the preventative maintenance program will review the following areas including but not limited to all facility areas are kept clean and in safe condition, ceiling tiles are free from watermarks or spots, drains are clean and free of debris. Facility provided document titled, Safety and Supervision of Residents dated 11/2024 which documents in part, our facility strives to make the environment as free from accident hazards as possible. Facility provided document titled, Pest Control Policy dated 11/2024 which document in part, the purpose is to prevent or control insects and rodents from spreading disease, and the facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents and garbage and trash containers shall be emptied when full and cleaned prior to returning to the appropriate area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145995 If continuation sheet Page 6 of 6