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 the
interviews and record reviews, the facility failed to provide the required staff assistance for bed mobility and
ambulation for dependent residents as per the MDS (Minimum Data Set) assessment.
This applies to 2 of the 3 residents (R1 and R2) reviewed for resident falls and injuries in a sample of 3.
The Findings Include:
1. R1 is an [AGE] year-old female admitted on the dementia floor on 8/18/22 with an admitting diagnosis,
including vascular dementia and multiple sclerosis.
On 12/31/24 at 9:25 AM, R1 was observed in her bed and was unable to move her lower extremities except
wiggling toes.
On 12/31/24 at 9:25 AM, R1 stated, I had a fall to the right side of my bed. My leg didn't move the way I
want to. I don't remember what my CNA was doing at that time.
A review of R1's fall risk assessment dated [DATE] document that R1 is high risk for fall.
A review of the R1's ADL (Activities of Daily Living) care plan document interventions including the resident
requires physical assistance by staff to turn and reposition when in bed.
A review of the MDS (Minimum Data Set) dated 11/6/24 document that R1 is dependent on bed mobility
requiring two or more helpers to complete the activity.
A review of the reportable document that the facility reported a fall for R1 on 11/14/24 while V3 (Certified
Nursing Assistant/CNA) was providing care to R1.
On 12/31/24 at 10:10 AM, V3 stated, I was on orientation when I provided care to R1, and R1 had a fall on
11/14/24. On 11/14/24, I entered R1's room to prepare her for mechanical lift transfer. I was alone in R1's
room. I put clothing on her and the sling under her for mechanical lift transfer. I was on her left side and
turned her to the right side to tuck in the sling. R1's leg was shaky and twitchy, and her leg slid over the side
of the bed, and R1 slid down on her buttocks. I was supposed to work with V7 (CNA), but V7 was out with
another resident.
On 12/31/24 at 11:20 AM, V7 stated, I am not sure why V3 turned R1 by herself. I told her to wait
(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 2
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
01/02/2025
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
for me, but she was overconfident that she could do it.
Level of Harm - Minimal harm
or potential for actual harm
On 12/31/24 at 11:10 AM, V2 (Director of Nursing/DON) stated, During the two weeks of orientation, the
new CNA (V3) works with a mentor to practice skills, learn processes, and learn the resident's habits. I
don't know why V7 (CNA) wasn't there. The orientee (V3) should have worked with her mentor to prevent
R1's fall.
Residents Affected - Few
On 12/31/24 at 10:45 AM, V8 (Restorative Nurse/RN) stated V3 was supposed to work with another staff
member during orientation to practice her skills and learn about resident-specific needs. As per our MDS
assessment, R1 requires two-person assistance for bed mobility.
2. R2 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular
dementia, Alzheimer's disease, and psychosis.
A review of R2's fall risk assessment dated [DATE] document that R2 is high risk for fall.
A review of the MDS (Minimum Data Set) dated 11/14/24 document that R2 requires partial moderate
assistance for ambulation.
A review of R2's care plan documents R2 was care planned for her limited mobility with interventions: The
resident requires physical assistance by staff to walk as necessary.
A review of the reportable documents the facility reported a fall for R2 on 12/12/24 with a laceration on her
right eyebrow requiring 3 stitches.
On 12/31/24 at 10:55 AM, V5 (Social Service Personal) stated, R2 is unsteady when she walks, and she is
supposed to be in her wheelchair with supervision as she tends to stand up abruptly. On 12/12/24, I saw R2
in her wheelchair in the activity room when I passed by the activity room. No staff was present in the activity
room to supervise residents. When I was about to exit the unit, I saw her standing and coming out of the
activity room and taking a few steps. R2 tumbled down face forward and hit the right side of her forehead,
causing a laceration that required three stitches. After R2's fall, I was the first to come to the scene; no
nurse, nursing assistant, or activity staff were in the activity room to monitor residents.
On 12/31/24 at 11:10 AM, V2 stated that someone should supervise dementia residents in the activity room
to prevent falls.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145853
If continuation sheet
Page 2 of 2
