Health inspection·February 22, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interviews and reviews, the facility failed to maintain a safe, comfortable home-like environment for one [R1] of four [R5, R7, R8] residents reviewed for smoking. Findings include,R1 was reviewed as a close record. R1 no longer resides in the facility. R1 intake details read: R1 reported, R7 constantly smoke in our room.R1's clinical record indicates in part: R1's medical diagnosis of anxiety disorder, bipolar disorder, paraplegia affecting right side, cerebral infarction, and asthma. Reviewed R1's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, care plans, medication administration record, treatment administration record, and progress notes. R7's clinical record indicated the following in part: R7's medical diagnosis of nicotine dependence, cognitive communication, dementia, major depressive disorder, memory deficit following cerebral infarction, and chronic osteomyelitis. Reviewed R7's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R7 is cognitively intact, care plans, medication administration record, treatment administration record, and progress notes. R7's Smoking Risk Review dated 1/28/26R7 has been continually educated on the importance of following facility policy and refraining from smoking in the room. Recommendations and outcome: R7 may not be capable of handling, carrying any smoking materials and requires supervision when smoking.R7's Smoking Contract dated 1/28/26, documented in part:R7 will not smoke anywhere else in the building. R7 will surrender all smoking materials to the facility. R7 will not carry on him, or possess in R7's room, or clothes any smoking materials.Consequences of violating smoking policy will result in losing smoking privileges. Further violations will be under review, may include involuntary discharge.R7's census documents R7 were R1's roommate from 1/23/26 through 1/27/26. R7's Care plain in part:R7 has a behavior of smoking cigarettes in his room dated 6/13/25.R7's social service progress notes documented in part R7 were observed smoking in his room on the following dates:6/13/25, 6/14/25, 6/19/25, 6/25/25, 8/20/25, 10/3/25, 10/17/25, 11/20/25, 1/25/26, 1/28/26, 2/12/26, and 2/13/26. V5 [Social Service Director] progress note:1/25/26 at 5:21PM- V5 met with R7 due to staff reporting R7 was smoking in his room. A room search was conducted with consent and R7 verbalized that he was smoking in the room. [R7 was roommates with R1 on 1/25/26 per R7's Census Report]. On 2/21/26 at 1:45 PM, R7 stated, I smoke in my room because I don't feel like getting up to go outside, and now its cold outside. I know the rules. I don't suppose to smoke in my room, but I don't care. On 2/21/26 at 10:18 AM, V11 [Licensed Practical Nurse] stated, I was R7's nurse on the first floor when he was roommates with R1. R7 smoked in the room. R1 did complain of smoking, because R1 had a diagnosis of asthma, and he did not want his asthma to flare up. R7 was moved to the third floor. On 2/21/26 at 2:10 PM, V11 [Licensed Practical Nurse] stated, R7 smokes in his room. However, we make rounds on him all the time to make sure he is not smoking and during smoke times we offer assistance to get him up so he can go outside and smoke. On 2/21/26 at 3:00 PM, V2 [Director of Page 1 of 2 145995 145995 02/22/2026 Archer Heights Healthcare 4437 South Cicero Chicago, IL 60632

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing] stated, I spoke with R1, regarding R7 smoking in their room. I completed a room change for R7 the same day. Nursing staff implemented interventions such as frequent rounds to ensure R7 is not smoking in the facility, encourage and assist R7 to attend outdoor smoking during designated times. R7 did admitted he was smoking in the R1 and his room. On 2/21/26 at 3:15 PM, V1 [Administrator] stated, R1 notified me that R7 was smoking in their room. R7 has a room change and is currently on a smoking contract. R7 has violated, and R7 agreed to be discharged to another facility. I responded to R1's concerns immediately. Policy documented in part:Facility Smoking Safety PolicyTo provide a safe and healthy living environment with respect for the health and well-being need of each resident.Smoking is only allowed in designated areas established by management. The interior of the facility will remain smoke-free at all times. 145995 Page 2 of 2