Archer Heights Healthcare

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

use the toilet urgently. Resident 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, Resident R4 stated his (Resident R4's) room is cleaned daily except for when V14 (Housekeeper) is assigned to clean his room. Resident 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.

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Printed: 04/13/2026 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

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)

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 (Resident R5).The findings include:Resident R5's Physician Order Sheet dated 11/12/2025 does not document a focus for self-administration of medication.Resident 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 Resident 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 Resident 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, Resident R5 stated she (Resident R5) was standing at the medication cart when V10 handed Resident R5 her medication and V10 walked away for a couple of seconds to take care of something else. Resident R5 stated I poured my own water and swallowed my medication followed by drinking the water. Resident R5 stated V10 never gives her (Resident 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

FORM CMS-2567 (02/99) Previous Versions Obsolete

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