Inspection·September 7, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The Care Plan dated 7/19/23 for R47 showed, R47 has an activity of daily living self-care performance deficit related to tremors on both hands. Ensure resident's privacy when performing and assisting with activities of daily living. The facility's Resident Dignity policy (4/4/223) showed, staff members shall strive to treat residents with dignity and respect. Staff shall strive to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures (pulling privacy curtain around bed, keeping the door closed during care, keeping the resident covered). Event ID: Facility ID: 145853 If continuation sheet Page 2 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop a care plan in a timely manner to address a pressure injury for 1 of 3 residents (R44) reviewed for pressure in the sample of 21. Residents Affected - Few The findings include: On 9/5/23 at 11:22 AM, R44 was sitting in the activity room in her wheelchair. R44 had pressure-relieving boots on both of her feet. R44's Skin/Wound Note dated 5/15/23 showed she had an unstageable DTI (deep tissue injury) to her left heel. The note showed the wound was an intact blister measuring 3.1 cm (centimeters) by 4.6 cm that was dark blue in color. R44's Skin/Wound Note dated 9/1/23 showed R44 still had the pressure injury on that date (over three months later). R44's care plans were reviewed, showing the care plan for her existing pressure injury was initiated on 9/5/23 (the same day the facility's annual survey had begun). A care plan, with a revision date of 7/26/23, was in place showing R44 had the potential for impairment to the integrity of her skin related to incontinence, however, the care plan did not mention her existing pressure injury, or her risk of developing a pressure injury. On 9/07/23 at 12:21 PM, V12 (Wound Nurse) said he just initiated the pressure ulcer care plan for R44 on 9/5/23. V12 said the care plan should be initiated as soon as the problem is identified. V12 said it is important to have the care plan in place, so staff know what the interventions are. The facility's policy and procedure titled Care Planning, with a revision date of 11/19/19, showed the purpose of the policy was to establish a course of action, with input from the resident, resident's family and/or guardian, or other legally authorized representative, the resident's physician, and interdisciplinary team (IDT) that moves a resident toward resident-specific goals .Crafting the how of resident care. The procedure showed a baseline care plan will be established within 48 hours of admission to ensure the resident's immediate care needs are met and maintained. The procedure showed the baseline care plan would remain in place until the IDT team could conduct the comprehensive assessment and develop an IDT care plan. The procedure showed the care plan is developed by the IDT team initially, then quarterly thereafter. The procedure showed care plan meetings will be scheduled within 21 days initially, then quarterly, annually, and significant change reviews thereafter. The procedure showed one of the care areas that need to have a plan of care developed to address concerns was pressure ulcer/injury. The policy and procedure showed 10. Throughout the course of rehabilitation or resident stay in the facility, the identified risk factors, goal, interventions, and outcomes on the care plan will be evaluated and revised as necessary. 11. The problem/strength statements will be dated as they occur. 12. The goal statement should be in measurable terms so progress or decline can be determined and have a review date. 13. Interventions should be written to help meet the goal. The intervention should be individualized to the resident. 14. A discipline or department which will be responsible for the intervention shall be identified. The facility's policy and procedure titled Nursing Services, with a revision date of 6/15/15, showed Nursing Care Plan: The Director of Nursing will see that the nursing needs of the resident are planned, supervised and evaluated by the registered professional nurses, and that a nursing care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 3 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0656 Level of Harm - Minimal harm or potential for actual harm is written and currently updated to meet these needs while respecting the individuality of each resident. The plan will indicate the needed nursing care, how it can best be accomplished, what methods and approaches are most successful, and what modifications are necessary to ensure best results. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 4 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe transfer for 1 of 1 resident (R107) reviewed for safety and supervision in the sample of 21. The findings include: On 9/5/23 at 10:56 AM, V3 CNA (Certified Nursing Assistant) took R107 in her wheelchair to her bathroom door. V3 had a gait belt around her own waist but did not place the gait belt on R107. V3 assisted R107 to standing by pulling on the back of the resident's pants in an upward motion. V3 told R107 to hold onto the grab bar in the bathroom. R107 was having trouble turning in the bathroom and V3 hooked her arm under R107's arm to turn her. V3 pulled R107's pants and incontinence brief down that was soiled with diarrhea. R107 then plopped down onto the toilet seat. After R107 was toileted, V3 hooked her arm under the resident's arm to have her stand and hold onto the grab bar. V3 then cleaned the resident's buttocks, pulled up a clean incontinence brief and her pants. V3 turned R107 and had her sit in her wheelchair. On 9/5/23 at 11:08 AM, V3 CNA stated R107 is weak sometimes. V3 stated sometimes R107 stands well and sometimes she doesn't. V3 stated she knows R107 and how she stands so she doesn't use the gait belt on her. On 9/6/23 at 12:09 PM, V4 RN (Registered Nurse) stated gait belts are to be used during transfers, ambulation and when a resident falls. V4 stated staff should use a gait belt when transferring a resident from the wheelchair to toilet and from the toilet to a wheelchair because it is still a transfer. V4 stated R107 was at high risk for falling, is shaky, and needs to have a gait belt on when she is being transferred. On 9/7/23 at 9:29 AM, V6 PT (Physical Therapist) stated gait belts are to be used anytime a resident is transferred or walked. V6 stated a gait belt is helpful to prevent falls and is a safety tool for staff to use. If a resident loses their balance the staff can hold onto the belt. V6 stated R107 is a fall risk and needs a gait belt on for all transfers. The Care Plan dated 8/11/23 for R107 showed the following: I have an ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion due to dementia and limited mobility due to osteoporosis and spinal stenosis of the lumbar region. Personal hygiene - R107 requires physical assistance by staff with personal hygiene and oral care. Toilet use - R107 requires physical assistance by staff for toileting. Transfer - R107 resident requires physical assistance by staff to move between surfaces as necessary; I have limited physical mobility related to weakness. Ambulation - R107 requires physical assistance by staff to walk as necessary. Locomotion - R107 requires physical assistance by staff for locomotion using wheelchair; I am at high risk for falls related to confusion, gait problems, incontinence and unaware of safety needs. Anticipate and meet the resident's needs. Provide a safe environment (even floors; free from spills and/or clutter; adequate, glare-free light; a working and reachable call light; handrails on walls, personal items within reach). The Incident Notes for August 2023 for R107 showed the following: 8/26/23 - Approximately 8:30 AM the nursing student observed R107 sitting on the floor beside her bed with legs extended out. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 5 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked resident what happened, R107 verbalized that she fell while trying to transfer from bed to wheelchair. 8/22/23 - CNA was outside of a resident's room, when she heard something hit the floor and then heard resident scream help. The CNA went to the room and found the resident on the floor, laying on her left side with her head laying on top the leg for the roommate's tray table. 8/14/23 - R107 was noted, by the activity aide, in her room sitting on the floor by the window with her back leaning on the wall and her legs lying straight. R107 said when she was trying to get off from bed her legs got caught on the blanket but blankets are all in her bed. The Minimum Data Set, dated [DATE] for R107 showed severe cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The Morse Fall Scale dated 8/26/23 for R107 showed she is at high risk for falling. The Face Sheet dated 9/6/23 for R107 showed medical diagnoses including urinary tract infection, extended spectrum beta lactamase resistance, dementia, anemia, hypertension, hyperlipidemia, anxiety disorder, depression, dysphagia, spinal stenosis, venous thrombosis and embolism, atherosclerotic heart disease, and osteoporosis. The facility's Accident & Incident Protocol (3/16/23) showed, Safety belt transfer information - a canvas belt (1/2 inch minimum) 48-54 inches long with safety buckles. It is an assistive device to protect employees and residents from injury. It provides the employee with a device to safely transfer and walk the residents. Place safety belt snugly around residents' waist. Transfer with safety belt: Be certain the belt is properly positioned and secured. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 6 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure a residents indwelling urinary catheter drainage bag was not on the floor for 1 of 2 residents (R50) reviewed for catheters in the sample of 21. The findings include: On 9/5/23 at 1:44 PM, R50 was lying on his back in bed with his bed in the lowest position. R50 had an indwelling urinary catheter, and the drainage bag was attached to the frame of his bed under his mattress The drainage bag was folded over under the bed and partially on the floor. On 9/5/23 at 1:48 PM, V4 RN (Registered Nurse) went into R50's room, looked at his catheter drainage bag, and stated it should not be on the floor because it could become contaminated. On 9/5/23 V2 DON (Director of Nursing) was not available for the survey. V2 was off for the week and could not be interviewed for privacy/dignity concerns. R5 RN (Registered Nurse) was available in the DON's absence. On 9/7/23 at 9:35 AM, V5 RN (Infection Control Preventionist) stated indwelling urinary catheter drainage bags should not touch the floor for infection control reasons. V5 stated the floor is dirty and that gets the bag dirty. Germs climb up the catheter and residents can get urinary tract infections. V5 stated the whole catheter system needs to be kept clean. The Face Sheet dated 9/6/23 for R50 showed diagnoses including right sided hemiplegia, cerebral infarction, dysphagia, speech and language deficits following cerebral infarction, benign prostatic hyperplasia, obstructive and reflux uropathy, retention of urine, urinary tract infection, klebsiella pneumoniae, metabolic encephalopathy, hypertension, hyperlipidemia, seizures, lack of coordination, anemia, polyarthritis, muscle weakness, vertigo, cerebral aneurysm, transient ischemic attack, acute kidney failure, and adjustment disorder. The Physician Orders for September 2023 for R50 showed: Maintain Enhanced Barrier Precautions for indwelling medical device usage (catheter). Indwelling catheter care every shift for urinary retention. The Care Plan initiated 7/19/23 for R50 showed, I have an indwelling catheter related to urinary retention secondary to benign prostatic hyperplasia with urinary obstruction and cerebral vascular accident. Anchor catheter to prevent excessive tension on the catheter. Change catheter every month and as needed; 16 French catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks each shift. Discontinue catheter as soon as clinically warranted. Exercise caution with mobility and positioning to avoid accidental removal. Monitor for evidence of catheter blockage; flush catheter per physician order; change catheter as indicated. Monitor for evidence of catheter leakage; flush catheter per physician order; change as indicated; avoid using larger catheter size unless medically justified. Position the drainage system (tubing, collection bag) to facilitate flow of urine. Use collection bag cover while in chair. R50's care plan did not show any intervention in pace for keeping the drainage bag off the floor. The facility's Catheterization policy (3/16/23) showed, Infection/Injury Control: Keep catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 7 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0690 tubing and drainage bag off the floor at all times (use privacy bag for drainage bag when resident is up in wheelchair). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 8 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure weekly weights were obtained for 1 of 8 residents (R44) reviewed for nutrition in the sample of 21. Residents Affected - Few The findings include: R44's admission Record, printed by the facility on 9/7/23, showed she had diagnoses including moderate dementia with behavioral disturbance, anemia, generalized anxiety disorder, psychosis, major depressive disorder, osteoarthritis, and an unstageable pressure injury to her left heel. On 9/5/23 at 12:27 PM, R44 was sitting in her wheelchair, by the entrance to the dining room on the memory care unit. R44 was being assisted and encouraged during the lunch meal by staff. R44 was drinking her juice and coffee. R44 ate less than 25% of the lunch meal. R44's facility assessment dated [DATE] showed she had moderately impaired cognitive skills for daily decision making. The assessment showed R44 had short-term and long-term memory problems and requires extensive assist of one staff member for eating. The assessment showed R44 had a weight loss of 5% or more in the month prior to the assessment, or a loss of 10% or more in the previous 6 months. V9's (Registered Dietitian) Nutrition/Dietary note dated 7/14/23 showed R44 was added to weekly weights due to a 6% weight loss over one month. V9's Nutrition/Dietary note dated 7/19/23 showed R44 had an unintentional weight loss, and she was underweighted. The note showed, Weekly weights obtained as well for weight loss. R44's Nutrition Risk assessment dated [DATE] showed R44 had a poor appetite and refuses foods. The assessment showed R44's average meal intake was between 5%-25%. R44's care plan, revised on 7/19/23, showed she had a potential nutritional risk and inadequate oral intake as evidenced by refusal of meals and significant weight loss. R44's Order Summary Report, printed by the facility on 9/7/23, showed an order for weekly weights, every Wednesday. The order date was 7/14/23, to be started on 7/19/23. The Order Summary Report showed the order for weekly weights was still active. R44's Weights and Vitals Summary Report, provided by the facility on 9/7/23, showed she weighed 134.0 pounds on 3/16/23, and she weighed 116 pounds on 9/6/23 (a loss of 18 pounds, or 13.4%, in the last 6 months). The report showed no weights were obtained for R44 on 8/16/23; 8/23/23; and 8/30/23. On 9/7/23 at 10:06 AM, V13 (CNA) said the residents' weights are documented in POC (Point of care-in the residents' electronic charting). No other place. V13 said the facility does not have any paper documents where the residents' weights are documented. V13 said if a resident's weights were obtained, it would be in POC. V13 said there is a gap in R44's weekly weights from 8/9/23-9/2/23. V13 said she believes the weekly weights should have been done. On 9/07/23 at 10:28 AM, V9 (Registered Dietitian) said staff should still be doing weekly weights for (R44). V9 said it looks like it fell off from August through September. It is important to do the weekly weights so that we have a constant trend of where her weights are going. V9 said there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 9 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0692 should have been weights done during that time. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled Weight Monitoring and Dietary Supplements, with a revision date of 5/31/23, showed, Residents will be weighed on admission, and then monthly afterwards, unless a physician orders otherwise. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 10 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to prevent cross-contamination for 4 of 4 residents (R15, R35, R83 and R88) reviewed for pureed foods in the sample of 21, and 4 residents outside the sample (R5, R54, R74, and R90). The findings include: On 9/06/23 at 9:02 AM, V10 (puree cook) was making the pureed foods for the lunch meal. V10 was putting 14 chicken breasts in the food processor to puree them for the lunch meal. While picking up some of the chicken breasts, 2 of the chicken breasts touched V10's visibly soiled apron. V10 put the chicken breasts that touched her soiled apron into the food processor with the other chicken breasts, added 2 cups of chicken broth, and turned on the food processor to puree the chicken. V10 added thickener to the food processor and turned it back on. V10 took the lid back off the food processor and put her gloved hand, (that she had used to move the pan the chicken was in, turn the food processor on and off several times, grab the handle of the pan containing chicken broth, and grab the container and the scoop to add thickener) inside the food processor. When V10 brought her hand out, there was pureed chicken on 2 fingers of her gloved hand. V10 turned the food processor on again and finished pureeing the chicken for the lunch meal. On 9/6/23 at 9:42 AM, V11 (Director of Culinary Services) said she was going to in-service V10 on the proper handling of food, using utensils and not letting her apron touch the foods. V11 said V10 should have used utensils to pick up the chicken and check the pureed consistency, and not let the food touch her apron/clothing, to prevent cross-contamination and food borne illness. The facility's document titled Diet Order Tally Report, printed on 9/7/23, showed 8 residents (R15, R35, R83, R88, R5, R54, R74 and R90) received pureed diets. The facility's policy and procedure titled Food Handling Guidelines, with a revision date of 4/12/19, showed Prevention of Food Infection .Minimize hand contact with food by the use of utensils and disposable gloves. The facility's document titled Culinary In-service: Proper Food Handling-Cooks, dated 9/6/23 showed Proper Food Handling with Utensils-In-Service Training for Cooks .Proper food handling minimizes the risk of contamination and foodborne illnesses, safeguarding the health of our residents .Cross-contamination: Prevent cross-contamination by using separate utensils for each food item. This ensures the safety of our residents with dietary restrictions or allergies .Glove Usage: Disposable gloves should be worn when handling ready-to-eat foods but remember that gloves are not a substitute for proper handwashing. Change gloves whenever they become contaminated, torn, or when switching tasks, such as handling raw and cooked foods or touching non-food items, such as your apron, hair, and face. Use of Utensils: Always use utensils like spatulas, tongs, or serving spoons to handle food. Avoid touching food directly with your hands or gloved hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 11 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care for 3 of 3 residents (R107, R47, & R35) reviewed for infection control in the sample of 21. Residents Affected - Few The findings include: 1. On 9/5/23 at 10:56 AM, V3 CNA (Certified Nursing Assistant) took R107 to the bathroom to be toileted. V3 pushed R107 in her wheelchair into the bathroom. V3 had gloves on and assisted R107 to stand. V3 told R107 to hold onto the grab bar. V3 pulled R107's pants and incontinence brief down. V3 removed R107's incontinence brief that was soiled with diarrhea. V3 had R107 sit on the toilet. V3 threw the soiled incontinence brief away, removed her gloves, and washed her hands. V3 went into R107's room and came back with an incontinence brief and disposable wipes. V3 put clean gloves on and put the clean incontinence brief around R107's legs above her pulled down pants. V3 assisted R107 to stand and hold onto the grab bar. V3 cleaned diarrhea off R107's buttocks and disposed of the wipes in the toilet. V3 grabbed a tube of cream from the back of the toilet, squirted it onto her contaminated gloves and applied the cream to R107's buttocks. V3 did not change her gloves. V3 pulled up R107's incontinence brief and then her pants. V3 pulled the bottom of R107's shirt down and assisted her to her wheelchair. V3 cleaned the diarrhea off the toilet seat, removed her gloves, and washed her hands. On 9/5/23 at 11:08 AM, V3 CNA stated she puts her gloves on when she goes in and provides cares. V3 stated she removed her gloves and washed her hands after she took R107's incontinence brief off because it was dirty. V3 stated she cleaned R107, put a new incontinence brief on R107, and pulled up her pants. V2 stated she then removed her gloves. V3 stated she felt that she did everything right and did not know when else she would have changed her gloves. V3 stated she was going to toilet another resident and to watch her again. On 9/6/23 at 12:09 PM, V4 RN (Registered Nurse) stated CNA's should remove their gloves after providing the care and before they touch anything else because of contamination/ infection control. On 9/7/23 at 9:35 AM, V5 RN (Infection Control Preventionist) stated when staff provide incontinence care and clean a resident then their gloves are dirty. They are contaminated. V5 stated the gloves should be removed and new ones put on before doing anything else like putting briefs on or pulling up the residents pants. V5 stated if a resident has a bowel movement and they are being cleaned those gloves are dirty and nothing else should be touched until new gloves are put on. It's important because we don't want to spread anything. It is cross contamination and a problem with infection control. V5 stated she has educated on glove changes and going from dirty to clean. The Care Plan dated 8/11/2023 for R107 showed the following: I have an ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion due to dementia and limited mobility due to osteoporosis and spinal stenosis of lumbar region. Personal hygiene - The resident requires physical assistance by staff with personal hygiene and oral care. Toilet use - The resident requires physical assistance by staff for toileting; I have bladder incontinence related to activity intolerance, confusion, history of urinary tract infection, physical limitations, and the use/side effects of metoprolol. I want to remain clean, dry and odor free without complications associated with incontinence thru the next review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 12 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Minimum Data Set, dated [DATE] for R107 showed severe cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene; occasionally incontinent of urine; frequently incontinent of bowel. The Face Sheet dated 9/6/23 for R107 showed medical diagnoses including urinary tract infection, extended spectrum beta lactamase resistance, dementia, anemia, hypertension, hyperlipidemia, anxiety disorder, depression, dysphagia, spinal stenosis, venous thrombosis and embolism, atherosclerotic heart disease, and osteoporosis. The facility's Infection Control - General policy (3/29/23) showed, the primary purpose of our Infection Control policies and procedures is to establish guidelines to follow in the prevention and spread of contagious, infectious, and communicable diseases. Standard precautions are the minimum infection prevention practices that apply to all patient/resident care, regardless of suspected or confirmed infection status. These practices make use of common-sense practices and personal protective equipment (PPE) use that protect healthcare providers from infection and prevent the spread of infection from resident to resident. Potentially contaminated fluids include: Blood and blood products, urine, feces, saliva, mucous membranes, wound drainage, cerebral spinal fluid. Gloves and handwashing - wear gloves when entering room while care is being provided. Change gloves after having contact with infective material and remove gloves before leaving the room. Perform hand hygiene immediately after glove removal, and, to ensure hands remain clean, do not touch potentially contaminated surfaces or items prior to leaving room. 2. On 9/5/23 at 11:09 AM, V3 took R47 in her wheelchair to the bathroom. V3 stated her hands were clean and she was going to put on gloves. V3 applied gloves. V3 assisted R47 to stand and hold onto the grab bar. V3 pulled R47's pants and incontinence brief down. R47 was incontinent of feces and V3 removed R47's incontinence brief. R47 sat down on the toilet and V3 removed her gloves. V3 left the bathroom, went into the residents room, and came back with a pad and incontinence brief. V3 put clean gloves on and put the clean incontinence brief with a pad in it around R47's legs above her pants. V3 assisted R47 to stand and hold onto the grab bar. V3 used toilet paper to clean the feces off R47. V3 grabbed a tube of cream/ointment from the back of the toilet, squeezed some onto her gloves, and placed the tube on the back of the toilet. V3 applied the ointment to R47's buttocks. V3 pulled up R47's incontinence brief and pants. V3 adjusted the bottom of R47's shirt and then removed her gloves. On 9/6/23 at 12:09 PM, V4 RN (Registered Nurse) stated CNA's should remove their gloves after providing the care and before they touch anything else because of contamination/ infection control. On 9/7/23 at 9:35 AM, V5 RN (Infection Control Preventionist) stated when staff provide incontinence care and clean a resident then their gloves are dirty. They are contaminated. V5 stated the gloves should be removed and new ones put on before doing anything else like putting briefs on or pulling up the residents pants. V5 stated if a resident has a bowel movement and they are being cleaned those gloves are dirty and nothing else should be touched until new gloves are put on. It's important because we don't want to spread anything. It is cross contamination and a problem with infection control. V5 stated she has educated on glove changes and going from dirty to clean. The Face Sheet dated 9/6/23 for R47 showed diagnosis including diabetes mellitus, hypertension, atrial fibrillation, deep venous thrombosis, dementia, vitamin D deficiency, anemia, osteoporosis, incontinence, essential tremor, cataract, and low back pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 13 of 14 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 145853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Baptist Village 4747 North Canfield Avenue Norridge, IL 60656 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Care Plan dated 7/19/23 for R47 showed, I am incontinent of bowel and bladder relate to diagnoses of diabetes mellitus, dementia and the use/side effects of medication (Bumex & metoprolol) and a detrusor instability. Brief use - R47 resident uses incontinence briefs with pads. Change when soiled and as needed. Clean peri-area with each incontinence episode. The Minimum Data Set, dated [DATE] for R47 showed extensive assistance needed for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing; balance during transitions and walking - not steady, only able to stabilize with staff assistance. The facility's Infection Control - General policy (3/29/23) showed, the primary purpose of our Infection Control policies and procedures is to establish guidelines to follow in the prevention and spread of contagious, infectious, and communicable diseases. Standard precautions are the minimum infection prevention practices that apply to all patient/resident care, regardless of suspected or confirmed infection status. These practices make use of common-sense practices and personal protective equipment (PPE) use that protect healthcare providers from infection and prevent the spread of infection from resident to resident. Potentially contaminated fluids include: Blood and blood products, urine, feces, saliva, mucous membranes, wound drainage, cerebral spinal fluid. Gloves and handwashing - wear gloves when entering room while care is being provided. Change gloves after having contact with infective material and remove gloves before leaving the room. Perform hand hygiene immediately after glove removal, and, to ensure hands remain clean, do not touch potentially contaminated surfaces or items prior to leaving room. 3. R35's admission Record (Face Sheet) showed an original admission date of 6/4/19 with diagnoses to include: dementia, palliative care, and osteoarthritis. R35's 7/31/23 Minimum Data Set (MDS) showed a Brief Interview for Mental Status score was not able to be done and he had short and long-term memory problems. The MDS showed he was totally dependent on one person for toilet use and personal hygiene; and he was totally incontinent of bowel and bladder. On 9/07/23 at 9:24 AM, V8 Hospice Certified Nursing Assistant began providing incontinence care for R35. R35 had a small bowel movement, which V8 cleaned. V8, using the same gloves, then began applying barrier cream, a clean brief and finally R35's clean clothing. On 9/07/23 at 11:11 AM, V5 Infection Preventionist stated gloves should be changed after cleaning a resident's bowel movement and prior to touching the resident or clean items. V5 stated this is to prevent cross-contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 14 of 14