Inspection visit

Health inspectionAugust 15, 2024

CENTRAL BAPTIST VILLAGECMS #1458535 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow a resident's plan of care to prevent and treat the development of facility-acquired pressure wounds for a resident at high risk for pressure wounds. This applies to 1 of 4 residents (R25) reviewed for facility-acquired pressure injuries in the sample 21. Residents Affected - Few The findings include: Face sheet, dated August 14, 2024, shows R25's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her right non-dominant side, congestive heart failure, vascular dementia, sacroiliitis, spinal stenosis, muscle weakness, venous insufficiency, and need for assistance with personal care. R25's historical skin integrity care plans showed R25 was identified to have a potential for skin impairment related to decreased mobility and incontinence on September 16, 2024. On July 16, 2024, R25 was identified to have developed a new facility-acquired a stage 3 pressure wound on her sacrum related to decreased mobility and incontinence. Intervention, initiated July 16, 2024 and revised on August 12, 2024, shows, Encourage the use of pressure-relieving devices such as specialized mattresses R25's care plan, reviewed August 14, 2024, showed R25 developed a new facility-acquired stage 2 pressure wound on her sacrum related to decreased mobility and incontinence (initiated August 12, 2024). Interventions, implemented August 12, 2024, included encourage the use of pressure-relieving devices such as specialized mattresses, cushions, heel troughs, and other devices and nursing staff to provide assistance to turn/reposition at least every two hours, more often as needed or requested. R25's care plan showed R25 had periods of bowel and bladder incontinence related to impaired mobility requiring staff to check R25 for the need to toilet or for incontinence every 2 to 3 hours. The care plan showed R25 required a mechanical lift device for transfers and the physical assistance of staff to turn and reposition her in bed. On August 14, 2024 at 11:04 PM, R25 was lying asleep in bed with her head of bed slightly elevated. R25 did not have a low air loss pressure relieving mattress in place. On August 14, 2024 at 11:12 AM, V23 (CNA-Certified Nursing Assistant) observed R25 lying in her bed and stated R25 did not have a low air loss mattress in place. On August 14, 2024 at 11:27 AM, V24 (Licensed Practical Nurse) stated R25 had no low air loss mattress on her bed and stated she had no physician order for a low air loss mattress for her pressure injury. (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 10 Event ID: 145853 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 08/15/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On August 14, 2024 at 1:22 PM with V2 (Director of Nursing - DON), V20 (Registered Nurse / Wound Care) stated R25's previously healed pressure wound reopened on August 12, 2024. V20 stated R25's original wound was a pressure wound and stated R25 may have developed the wound because maybe she was on the back too much. When asked why R25 did not have a low air loss pressure relieving mattress V20 stated, I missed it. V2 (DON) stated R25 should have had a low air loss pressure reliving mattress put in place when she developed her initial pressure wounds on July 15, 2024 and R25 should have a pressure relieving low air loss mattress in place since the development of the re-opened pressure wound on August 12, 2024. Nursing progress note, dated July 15, 2024, shows R25 was identified as having an open area/wound on her sacral area, measuring 0.5 cm (Centimeters) in diameter, and requiring foam dressing treatment daily. Initial Skin Observation Tool, dated July 16, 2024, shows R25 was identified to have two newly identified facility-acquired pressure wounds: 1. one pressure wound / suspected deep tissue injury on her right sacrum (0.3 cm x 0.4 cm x 0.0); and 2. second pressure wound on her left sacrum (0.5 cm x 0.5 cm x 0.1 cm) which was identified as a Stage 3 wound. Weekly Wound Assessment, dated July 24, 2024, shows R25's right sacral wound was determined to be healed. The Weekly Wound Assessment, dated July 24, 2024 and intending to identify R25's left sacral pressure wound, shows R25's pressure wound was improving. Weekly Wound Assessment, dated July 31, 2024, shows R25's left sacral pressure wound was healed. Initial Skin Observation Tool, dated August 12, 2024, shows R25 was identified to have a newly developed facility-acquired pressure wound. Facility Policy and Procedure Pressure Area Prevention and Treatment, revised July 8, 2015, shows, Stage I Pressure Areas: .Interventions: 3. Implement pressure relieving devices (water mattress, wheelchair cushions, etc.) . The policy/procedure shows interventions for pressure wounds stages 2, 3, and 4 were expected to include all Stage I interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 2 of 10 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 08/15/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their policy to administer medications as ordered by the physician. There were 33 opportunities with 3 medication administration errors resulting in a 9.09% medication error rate. This applies to 2 of 4 residents (R65, R73) reviewed for medication administration in the sample of 21. Residents Affected - Few The findings include: 1. On August 13, 2024, at 8:59 AM, V14 (MDS/Minimum Data Set Coordinator) prepared R65's morning medications, including one tablet folic acid 800 mcg (micrograms), one tablet gabapentin 300 mg (milligrams), one tablet losartan/hydrochlorothiazide 50/12.5 mg, one tablet metoprolol tartrate 50 mg, one tablet potassium chloride 20 mEq (milliequivalents), one tablet PreserVision eye vitamin, one tablet vitamin B12 500 mcg, and one tablet vitamin D3 50 mcg for a total of eight tablets. V14 also prepared one capful of polyethylene glycol mixed in a cup of water. On August 13, 2024, at 9:08 AM, V14 said she was ready to administer R65's medications and counted nine tablets to be administered to R65. V14 was stopped by the surveyor and asked to compare R65's medications with the medications in the cup. V14 said there was an extra pill in the medication cup which was not one of R65's medications. The pill in the cup was a white oblong pill marked with HH on one side and 327 on the other side. Medicine.com identifies the medication as irbesartan 75 mg (blood pressure medication). R65's Order Summary Report dated August 13, 2024, at 12:09 PM, does not show a physician order for irbesartan. On August 13, 2024, at 9:15 AM, V14 assisted R65 with one sip of the polyethylene glycol mixture. At 9:16 AM, V14 walked away from R65 and threw the polyethylene glycol mixture in the garbage. R65 had not refused the medication. On August 14, 2024, at 2:51 PM, V2 (DON/Director of Nursing) said R65 should not receive medications not prescribed to R65. V2 continued to say V14 should have administered R65's complete dose of polyethylene glycol since R65 did not refuse the medication. 2. On August 14, 2024, at 9:17 AM, V11 (Agency RN/Registered Nurse) prepared R73's morning medications, including one tablet empagliflozin 10 mg. R73's Order Summary Report dated August 14, 2024, showed an order dated March 2, 2024, for empagliflozin oral tablet 10 mg, give one tablet by mouth one time a day related to type 2 diabetes mellitus with hyperglycemia, before breakfast. On August 14, 2024, at 10:24 AM, V11 said R73's medications were administered after R73 ate breakfast. On August 14, 2024, at 2:51 PM, V2 (DON) said R73's empagliflozin should have been given before breakfast, as ordered. The facility's policy titled Medication Administration dated April 10, 2024, showed, Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 3 of 10 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 08/15/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Statement: Unless otherwise specified by the physician, medications will be administered within sixty minutes before or after dosing schedule, except before or after meals. Purpose: 1. To provide uniform and efficient practices in safe medication administration. 2. To optimize therapeutic dosage levels. Procedure: 1. Licensed nursing professionals administer medications according to times of administration . 3. Medications ordered to be fine before meals are administered approximately thirty minutes before meal time . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 4 of 10 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 08/15/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to serve portions of Garlic Herb Roasted Pork Tenderloin to residents receiving mechanically altered diets as planned on the approved facility menu. This applies to 5 of 5 residents (R1, R41, R52, R62, and R87) reviewed for portion sizes. The findings include: Resident Summary Report, printed August 12, 2024, shows R1, R41, R52, R62, and R87 were to all be served ground meats at meals. Spread sheet, dated August 12, 2024, shows residents with regular diets were to be served 4 ounces of Garlic Herb Pork Tenderloin and residents receiving Ground Meat or Mechanical Soft diets were to be served ground garlic herb pork using a 4 oz spoodle spoon. On August 12, 2024 at 12:07 PM on the first floor during lunch service, V17 (Food Service Worker) stated he was using a three ounce scoop to serve portions of ground Garlic Herb Roasted Pork Tenderloin to residents. V17 stated he was concerned he did not have enough ground pork product for lunch service to residents, so he changed the serving size from 4 ounces to 3 ounces to have enough ground pork for residents. V17 portioned out one scoop of the ground pork to the following residents on their lunch plates: R1, R41, R52, R62 and R87. On August 12, 2024 at 2:12 PM, V18 (Assistant Food Service Manager) weighed one portion of ground pork which weighed 3.4 ounces total. On August 12, 2024 at 12:21 PM, V18 (Assistant Food Service Manager) stated the ground pork was planned on the menu to have been served with a 4 ounce volume scoop. On August 13, 2024 at 1:25 PM, V19 (Dietitian) stated the portions of ground pork served on August 12, 2024 should have weighed a total of 4 ounces which was the same serving weight planned to be served the residents receiving regular diets in the facility. V19 stated the kitchen utilized standard guidelines to prepare ground meats for ground diets but there were no standardized recipes in use for the menu items. On August 12, 2024 at 12:54 PM, V16 (Executive Chef) stated the food service did not have standardized recipes for the preparation of ground diet items. Facility Garlic Herb Roasted Pork Tenderloin recipe, revised May 15, 2024, shows the recipe standard portion was 4 ounces. Facility policy and procedure Modified Texture Foods, revised January 2024, shows The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by the menu diet spreads. In the instance a substitute is needed, a comparable menu item will be provided Portions of modified-texture menu items will be provided in the proper amounts according to menu diet spreads Facility Dining Inservice Education Portion Size and Proper Weights, dated April 14, 2023, shows, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 5 of 10 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 08/15/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The diet spreadsheet indicates portion sizes and its corresponding utensil for adequate volume portioning. The spoodles are generally used as a volume portion, with each size representing the volume of the product. We need to ensure that if using a spoodle, the weight of the product matches what is required on the diet spreadsheet Facility document Handhelds, undated, shows handheld conversions for single proteins were to be served as slider sandwiches portioned into a minimum of three individuals portions prior to preparation. Facility diet spreadsheet, dated August 12, 2024, shows no diet spread for finger foods or small portions diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 6 of 10 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 08/15/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to offer/provide residents food substitutions equivalent in nutritive value to the originally planned/served menu items. This applies to 4 of 4 residents (R54, R57, R83, and R96) reviewed for food substitutions. The findings include: On August 12, 2024, V17 (Food Service Worker) plated the following food items on plates for residents during meal service: 1. R54 received a half sandwich (1 piece of bread cut in half) with no cheese and 2 half slices of thinly sliced ham between the half pieces of bread. R54's tray ticket showed R54 was to receive a regular/general diet with no further modifications. 2. R96 received a half sandwich (1 piece of bread cut in half) with no cheese and 2 half slices of thinly sliced ham between the half pieces of bread. R96's tray ticket showed R96 was to receive a regular/general diet with finger foods and small portions. 3. R57 received a half sandwich (1 piece of bread cut in half) with a very thin layer of peanut butter and jelly between the half pieces of bread. R57's lunch tray ticket, dated August 12, 2024, shows R57 was to receive a regular/general diet with a finger food modification. 4. R83 received a half sandwich (1 piece of bread cut in half) with a very thin layer of peanut butter and jelly between the half pieces of bread. R83's tray ticket, dated August 12, 2024, showed R83 was to receive a regular/general diet with finger foods and small portions. On August 12, 2024 at 12:27 PM, V18 (Assistant Food Service Manager) stated the staff used one individual portion cup of peanut butter to prepare the half peanut butter/jelly sandwiches served during the lunch. V18 also stated the staff used one piece of sliced ham which they cut in half to prepare the half ham sandwiches served during the lunch. V18 stated he believed the one slice of ham from the half sandwich weighed less one once of meat. On August 12, 2024 at 12:51 PM, V15 (Food Service Director) examined the half ham sandwiches and half peanut butter jelly sandwiches served to residents as substitutions and stated the ham on the half sandwiches appeared to weigh less than an ounce of meat and the peanut butter/jelly sandwiches appeared to be made with only one individual portion cup of peanut butter. V15 stated unless the residents required small portions the sandwich substitutions should contain protein equivalent to the menu items of the regular entrees served at the meal. On August 12, 2024 at 2:12 PM, V18 (Assistant Food Service Manager) weighed the slice of ham served on one of the half sandwiches during lunch which weighed 0.7 ounces total. Spread sheet, dated August 12, 2024, shows regular portions of the garlic herb pork served at lunch were to be served in 4 ounce weight portions. On August 12, 2024 at 12:54 PM, V16 (Executive Chef) stated the facility food service did not have a spreadsheet diet for finger foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 7 of 10 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 08/15/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm On August 13, 2024, V19 (Dietitian) stated the menu items served to residents during August 12, 2024 lunch service should have contained three total ounces of protein. V19 stated the substitutions served for the lunch menu entrees should have contained equal protein to the planned menu items served. V19 stated residents requiring finger foods should have received the regular menu items as planned but placed between two slices of bread or on a hot dog bun and served to the residents. Residents Affected - Some Facility policy and procedure Resident Food Preferences, Substitutes, and Portion Sizes, revised September 4, 2023, shows, The dietitian can determine if small or large portions are necessary. Small portions are 2 ounces of protein Sliced ham product detail provided by facility food service shows each slice of ham utilized on August 12, 2024 weighed 0.5 ounces per slice. Peanut Butter plastic portion control cup product detail provided by facility food service shows each portion cup of peanut butter contained 0.75 ounces of peanut butter. Facility policy and procedure Modified Texture Foods, revised January 2024, shows The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by the menu diet spreads. In the instance a substitute is needed, a comparable menu item will be provided Facility Dining Inservice Education Portion Size and Proper Weights, dated April 14, 2023, shows, The diet spreadsheet indicates portion sizes and its corresponding utensil for adequate volume portioning. The spoodles are generally used as a volume portion, with each size representing the volume of the product. We need to ensure that if using a spoodle, the weight of the product matches what is required on the diet spreadsheet Facility Ham Sandwich Recipe, printed August 14, 2024, shows 2 ounces of ham was to be placed on 2 slices of bread for each whole sandwich. Facility Peanut Butter and Jelly Sandwich recipe, printed August 14,2024, shows 1 ounce of peanut butter (2 Tablespoons) was to be placed on 2 slices of bread for each whole sandwich. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 8 of 10 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 08/15/2024 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 Based on interview and record review, the facility failed to document and track HCP (Health Care Providers) covid test results during a covid outbreak in accordance with their policy. This applies to all 102 residents who reside in the facility. Residents Affected - Many The findings include: The form 671 completed on August 12, 2024, showed a facility census of 102. Upon annual survey entrance conference on August 12, 2024, at 9:30 AM, V1 (Administrator) stated there are 16 covid positive residents on the second floor. On August 14, 2024, at 10:17 AM, V3 (IP-Infection Preventionist)) stated R66 tested positive for covid on August 8, 2024, and was tested by a nurse on the second-floor unit due to displaying symptoms of covid. V3 was unable to provide testing results of HCP (Health Care Providers) who were exposed to R66. V3 stated in response to R66 positive test results, all the residents on the second floor were tested for covid, but HCPs tested themselves and V3 did not have any documentation to validate HCP testing. V3 provided a list of staff who had tested positive for covid, titled Staff Syndromic Surveillance for Covid 19, which showed the first staff member tested positive on July 31, 2024, V25 (the Nurse Educator), who potentially interacted with all staff on both the first and second floors, was tested after displaying symptoms of covid. The next staff on the list who tested positive, on August 2, 2024, was V26 (Rehab/Restorative Nurse), who had potential contact with all residents and staff on the first and second floor, also displayed symptoms of covid at the time of testing. On August 4, 2024, the list showed 2 more staff tested positive, V27 (Social Services staff, for the second floor) and V28 (Social Services staff for the first floor) who both displayed symptoms of covid at the time of testing. The Social Services office is adjacent to V25 's office on the first floor. V25 had to walk past the social services office of V27 and V28 to gain access to his office. The list showed on August 6, 2024, 2 more staff tested positive, 1 more Social Services staff and a Nurse who worked the second floor, both who showed symptoms of Covid at the time of testing. V21 (CNA) tested positive for covid on August 11, 2024. The nursing schedule showed V21 worked on the first floor on August 9, 2024, 48 hours prior to becoming symptomatic and testing positive for covid. V22 (CNA) tested positive for covid on August 11, 2024, and the nursing schedule showed V22 had worked on the second floor on August 9, 2024, 48 hours prior to testing positive for covid. The list titled Resident Syndromic Surveillance for Covid-19 showed on August 14, 2024, four additional second floor residents tested positive for covid, for a total of 21 since August 8, 2024. On August 14, 2024, at 1:50 PM, V4 (Culinary Aide) stated she had served meals from the second-floor satellite kitchen, where residents are still eating in the dining room, both today and last week and has not been tested for covid during that time. On August 14, 2024, at 2:00 PM. V5 (Activity Aide) worked on the second floor, stated no one told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 9 of 10 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 08/15/2024 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 me what to do regarding covid testing, all I know is if I don't feel good, I should test myself. Level of Harm - Minimal harm or potential for actual harm On August 14, 2024, at 2:50 PM, while working on the second floor, V13 (CNA) stated she has not tested for covid since the outbreak started. Residents Affected - Many On August 14, 2024, at 2:35 PM, while working on the second floor, V10 (CNA) stated he would go to the office for a covid test only before returning to work after being sick. On August 14, 2024, at 2:30 PM, while working on the second floor, V9 (Nurse) stated you test for covid on your own, if you don't feel good at work, test yourself. On August 14, 2024, at 2:40 PM, while working on the second floor, V11 (Nurse regularly scheduled from agency) stated nobody told me about testing for covid, I test myself whenever I want. On August 15, 2024, at 10:02 AM, V2 (Director of Nursing) identified that V25, (Nurse Educator) had contact with staff on both the first and second floors. V2 stated V26 (Restorative Nurse) had contact with both residents and staff on both the first and second floors. V2 stated V27 is the social services staff for the second-floor residents and V28 is the social services staff for the first-floor residents. V2 stated there were no new covid positive residents identified today on August 15, 2024. On August 14, 2024, at 1:31 PM, V2 (DON) stated she does not have tracking of staff covid testing to validate staff have tested after being exposed to covid 19. V2 stated she thought V3 (IP-Infection Preventionist) did that tracking. On August 14, 2024, at 10:17 AM, V3 (IP) stated it was too much to track the testing of staff, so she just tracked the residents and stated staff just test themselves when they have symptoms. V3 did not provide HCP (Health Care Provider) covid test results for staff who had potential exposure to V25, V26, V27, V28, within 24 hours of their positive covid test. V3 did not provide HCP covid outbreak testing results for the second-floor staff at the time of the outbreak testing for second floor residents on August 9, 2024. The Facility's policy titled Covid 19 testing/mitigation dated March 20, 2024, Purpose .Testing is a valuable tool to help control the spread of Covid-19 through early identification of positive cases and is part of the overall Covid -19 plan .Testing plan and response .b. If one positive staff member or resident is identified the unit is considered to be in outbreak. All staff and residents in the affected unit and potentially exposed should be tested immediately (no sooner than 24 hours after exposure) and then .all exposed staff and residents that previously tested negative should be retested within 48 hours after the initial negative test, and again 48 hours after the second negative test. After the initial testing series testing should continue every 48-72 hours until no new positive cases have been found for 14 days .The definition of a higher risk exposure: An exposure to a staff member to a person with COVID in any of the following circumstances .1. Staff member not wearing either a face mask or respirator .and Implement Source Control Measures .The SARS-Cov-2 virus can spread from individuals who do not have symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145853 If continuation sheet Page 10 of 10

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Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0806GeneralS&S Epotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2024 survey of CENTRAL BAPTIST VILLAGE?

This was a inspection survey of CENTRAL BAPTIST VILLAGE on August 15, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CENTRAL BAPTIST VILLAGE on August 15, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 15, 2024