Health inspection·November 13, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to ensure a homelike environment due to uncleanliness of resident's rooms noted with paper, trash, and debris throughout residents' rooms. This failure affected 4 of 5 residents (R1, R2, R4, R6, and R7) reviewed for homelike environment.R1's Minimum Data Set Section C dated 11/3/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R2's Minimum Data Set Section C dated 9/4/2025 documents a BIMS (Brief Interview Mental Status) Score of 6 which is indicative of a severely impaired cognition.R4's Minimum Data Set Section C dated 10/27/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R6's Minimum Data Set Section C Dated 10/1/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R1's care plan dated 8/21/2025 documents, in part, no focus for hoarding.R2's Care Plan dated 9/17/2025 documents, in part, no focus for hoarding.R4's Care Plan dated 11/11/2025 documents, in part, no focus for hoarding.R6's Care Plan was reviewed and requested from the facility's administrator but was not received; documents, in part, no focus for hoarding. On 11/10/2025 at 2:34 pm, R1 stated the housekeeper does not come and sweep the floor or mop in his room. R1 stated he has asked the housekeeper to clean his room several times throughout the last 2 weeks, but no one has done any cleaning. Surveyor observed trash on the floor and under his (R1's bed). Surveyor observed a plastic medication cup with R2's room and bed number and PM written on side of the cup, a white paper medication cup with R2's last name, napkins, and plastic silver ware wrappings under R2's bed (R1's roommate). Surveyor noted trash and debris throughout R1's and R2's room. On 11/10/2025 at 2:41 pm, R2 stated he (R2) there is trash all over the floor in his room all the time.On 11/12/2025 at 11:05 am, V8 (Regional Nurse Consultant) housekeeping cleans rooms daily changing bed linens once per day and as needed. V8 stated the floor nurses must ensure the unit stays clean and that housekeeping makes frequent rounds.On 11/12/2025 at 1:12 pm, V14, Housekeeper, was observed standing in the hallway with a cleaning cart by R6's and R7's room. Surveyor entered R6's and R7's room and observed the following items by R6's bed: 3 empty water bottles, 2 empty nutritional supplement bottles, paper, napkins, an undated breakfast meal tray slip that was stuck to the floor, salt and pepper paper wrapping, 1 plastic cup, 2 brown paper towels and a butter cup. V14 entered the room and verified the above-named items on R6's floor. V14 stated R6's family brings R6 many grocery items and R6 is a hoarder. V14 stated she cleaned R6's room this morning. V14 stated the purpose of cleaning residents' rooms daily is to keep a clean environment and to prevent residents from getting sick due to not maintaining infection control measures. On 11/12/2025 at 2:22 pm, R6 stated housekeeping cleaning her (R6's) room about 10 days ago; my (R6's) room was not cleaned this morning; she (R6) went to the bathroom two times recently and noticed stool on the toilet and when she reported it to the staff the bathroom was not cleaned for a long time; and she reported the uncleaned toilet several times because she needed to (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 3 Event ID: 145995 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 11/13/2025 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)