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 Page 1 of 3 145995 145995 11/13/2025 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some use the toilet urgently. R6 stated she could not recall the dates the incidents occurred or which staff she reported the uncleanliness to. On 11/12/2025 at 2:40 pm, R4 stated his (R4's) room is cleaned daily except for when V14 (Housekeeper) is assigned to clean his room. R4 stated he had put trash on the floor and left his room intentionally to see if V14 would sweep the trash up and when he returns to his room the trash remained on the floor. Facility Policy titled Policy and Procedure for Safe, Clean, Comfortable and Homelike Environment dated 10/24 documents, in part, The facility will provide a safe, clean, comfortable, and homelike environment to the residents while taking into consideration a person-centered care, where residents' independence is promoted.Facility Policy titled Housekeeping dated 7/2025 documents, in part, To provide guidelines to maintain a safe and sanitary environment forresidents, facility staff and visitors. 145995 Page 2 of 3 145995 11/13/2025 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper administration of medication due to a resident standing at the medication cart taking medication without a nurse's observation to ensure the resident swallowed the medication. This failure affected 1 of 1 resident (R5).The findings include:R5's Physician Order Sheet dated 11/12/2025 does not document a focus for self-administration of medication.R5's Minimum Data Set Section C dated 11/5/2025 documents a BIMS (Brief Interview Mental Status) of a 15 which is indicative of an intact cognition.On 11/12/2025 at 12:32 pm, surveyor observe the medication cart across from the nursing station and R5 putting a medication cup containing several tablets in her mouth followed by drinking water without a nurse present. On 11/12/2025 at 12:33 pm V10, LPN walked pass the surveyor and went behind the nurse's station. V10 stated she (V10) was done passing medication. V10 stated she (V10) did not observe R5 take her medication because she (V10) was doing multiple tasks at one time. V10 stated the purpose of observing residents take their medication is to make sure the resident swallows the medication. On 11/12/2025 at 10:57 am, V2 (Director of Nursing) stated self-administration of medication requires a physician's order, resident education, a care plan, and an assessment to ensure the resident understands the process. V2 stated the purpose of these interventions are necessary for safety and to ensure the resident benefits from the prescribed medication. On 11/12/1015 at 11:02 am, V2 (Director of Nursing) explained that nurses receive comprehensive training in hand hygiene, vital signs, and safe medication administration. V2 stated nurses must not leave medication cups at the bedside due to safety concerns. V2 stated while some residents keep plastic medication cups for personal reasons such as for lotion, nurses are required to check that medications are swallowed. On 11/12/2025 at 2:49 pm, R5 stated she (R5) was standing at the medication cart when V10 handed R5 her medication and V10 walked away for a couple of seconds to take care of something else. R5 stated I poured my own water and swallowed my medication followed by drinking the water. R5 stated V10 never gives her (R5) medication and walks away, she (V10) was just busy at the time. Facility Policy titled Medication Policy dated 10/25/2014 documents, in part, Medications are administered in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility have sufficient staff and a medication distribution system to ensure safe administration of medication without unnecessary interruptions. Residents Affected - Few 145995 Page 3 of 3