Central Nursing Home

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

for toileting hygiene, showering/bathing, personal hygiene. Resident R12 is dependent on staff for chair/bed to chair transfers. Resident R12's MD also indicates she is always incontinent of urine and bowel. Facility provided policy titled Resident Rights dated 06/01/22 which documents in part the federal and state laws guarantee certain basic rights to all residents of this facility and these rights include the resident's right to: a dignified existence and be treated with respect, kindness and dignity.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet

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

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Central Nursing Home

2450 North Central Avenue Chicago, IL 60639

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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Resident R11 received in the dining room, stated he pushed his index finger (showed the surveyor his index finger)

on the left side of Resident R10's face (pointed his finger on the lower left of his face), but he did not know why he pushed his finger on her face. He also stated that he saw little blood on Resident R10's face, he felt bad, and he will be mad if someone pushed finger on his face. He has not seen Resident R10 since the incident, no one has been abusive to him, and he feels safe in the facility.Nurses progress notes on 12/15/25 document in part: Resident (Resident R11) was assessed following an incident in which he struck another resident (Resident R10) in the face while passing her in the hallway.Police report dated 12/15/25 document in part: Battery Simple.Resident R10's skin only evaluation dated 12/20/25 document in part, skin abrasion, left face.Resident R11's Trauma, abuse, neglect screening assessment dated [DATE REDACTED].Abuse Policy, undated, document in part: Residents have the right to be free from abuse.

Event ID:

Facility ID:

If continuation sheet

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

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Central Nursing Home

2450 North Central Avenue Chicago, IL 60639

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

allegations need to get reported to the State Agency within two hours of the event and when V2 does submit to the State Agency she does it via email. V2 stated the State Agency does not send her a confirmation email so what she does is print out a copy of the email she sent to the State Agency which has the date/time sent and includes this email with the other paperwork for the abuse allegation/investigation as confirmation the State Agency was notified. V2 stated like she said she had no involvement in this case initially. V2 stated for the final report she did get involved in the interviewing part of

the investigation but V1 did not ask her to send the initial or final to the State Agency.On 12/31/25 at 12:15 PM, V1 stated V2 keeps saying that V1 did the initial submission on 12/15/25 but V1 was under the impression that V2 was doing it. V1 said, most of the time it is me. I don't remember doing it. I thought the Director of Nursing was doing it. V1 stated it might have been a miscommunication problem. Surveyor with V1 looked through the other abuse reportables from the past three months and noted there is a confirmation of the report sent to the State Agency along with the investigation report for all of them except

the incident on 12/15/25. V1 stated incident on 12/15/25 is missing because she does not think it was done.

V1 stated if the State Agency does not have a record of the submission, then that means it was not done.

V1 stated it is important to notify the State Agency within two hours because the State Agency needs to be made aware of the situation and know what the facility did so the residents are not in danger anymore and free from abuse.On 12/24/25 at 2:38 PM, surveyor confirmed with a Public Service Administrator at the State Agency that the facility did not submit a facility report for the incident on 12/15/25 involving Resident R10 and Resident R11.Facility provided initial report for incident date 12/15/25 involving Resident R10 and Resident R11 undated, not timed and with no evidence of submission to the State Agency.Facility provided final report for incident date 12/15/25 involving Resident R10 and Resident R11 undated, not timed and with no evidence of submission to the State Agency.Facility provided policy titled Abuse Investigation and Reporting undated which documents in part, all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and an alleged violation of abuse will be reported immediately but not later than two hours if

the alleged violation involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse and has not results in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

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

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Central Nursing Home

2450 North Central Avenue Chicago, IL 60639

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews and record reviews, the facility failed to follow their policy to investigate and prevent further allegation of abuse. This failure affects one (Resident R2) out of three residents reviewed for abuse. Findings Include: On 12/23/25 at 2:58 PM, via telephone, Resident R2 stated that V21 (Certified Nursing Assistant/CNA) was verbally abusive to her because she said that Resident R2 cannot clean her own a** and she will get to Resident R2 when she is able. Resident R2 cannot remember the date/time and there was no witness. Resident R2 also stated that V22 (Restorative Aide) played mental games with her by showing up to provide restorative therapy and often came to her when she is doing something else.On 12/23/25 at 3:58 PM, Surveyor informed V1 (Administrator) that Resident R2 has allegation of verbal abuse against V21, and mental abuse against V22, she stated she has no report against V21 and V22 by Resident R2, but she will follow up. On 12/26/25 at 4:12 PM, V1 stated the facility protocol/policy on staff to resident abuse is that the employee would be immediately suspended and not be allowed to return until her investigation is complete however this is different because she concluded her investigation prior to those employees being scheduled again. This situation is different because Resident R2 is no longer in the building, and she cannot afford not to have staff here especially over the holidays so even though she has five days to complete her investigation, she completed as soon as she could so that she would not have to suspend any employees. V1 also stated that she notified V21 and V22 on 12/23/25 that there was an allegation of abuse against them and completed her investigation on 12/24/25. She talked to V22 on 12/23/25 on the phone about the allegation and interviewed him then. She finished the interviews related to V22 on 12/24/25. V22 was not working on 12/24/25 or 12/25/25. She talked to V21 on 12/23/25 about the allegation, interviewed her and finished all the interviews she needed related to V21 on 12/23/25.

She felt comfortable letting her come to work on 12/24/25. Because she was able to make the determination right away the staff was allowed to return to work and did not need to be suspended. On 12/31/25 at 12:32 PM, V1 stated that technically, she had already made the decision on 12/23/25 not to substantiate the allegation so the interviews she did on 12/24/25 were not going to have an impact on her decision. Because of this she does not have any problem bringing them back to work. She allowed both to work on 12/24/25 because she had finished her investigation on 12/23/25. On 12/24/25 at 11:15 AM, V22 (Restorative Aide) stated that he did not abuse Resident R2 mentally; he did not play mental games with her by asking to provide her restorative program when she was in the middle of something. On 12/30/25 at 11:02 AM, surveyor observed V22 on the first floor, stated that 12/24/25 was the first time V1 spoke with him about mental abuse allegation by Resident R2.On 12/24/25 at 12:04 PM, V21 (CNA) stated she is familiar with Resident R2,

she was not verbally abusive to her, she did not abuse her, and she did not tell Resident R2 that she cannot wipe her own a**.On 12/31/25 at 11:01 AM, V2 (Director of Nursing/DON) stated that it is the policy of the facility to suspend immediately any staff accused of abuse pending the final investigation to protect other resident from potential abuse. If the alleged staff is on duty at the time of the report, the staff should punch out immediately, but if the alleged staff is out of the facility at the time of the report, the facility will notify the staff not to come to work while investigation is ongoing.Documents reviewed for this investigation are not limited to the following: Abuse Policy documents in part: Protect residents from any further harm during investigations.Abuse Investigation and Reporting documents in part: The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Abuse in-service attendance record dated 6/23/25, and 9/7/25. Reportable dated 12/23/25, and final faxed to the State Agency on 12/30/25.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Central Nursing Home

2450 North Central Avenue Chicago, IL 60639

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to administer medication as prescribed by the physician.

This failure affects two (Resident R2, Resident R4) out of five residents reviewed for medication administration. Findings Include: Resident R2's Electronic Health Record/EHR shows she was admitted to the facility on [DATE REDACTED], she is [AGE] years old with a Brief Mental Status/BIMs score of 15. Resident R2 has diagnoses not limited to Glaucoma, anxiety disorder, and major depressive disorder.Resident R4's Electronic Health Record/EHR shows he was admitted to the facility on [DATE REDACTED], he is [AGE] years old with a Brief Mental Status/BIMs score of 15. Resident R4 has diagnoses not limited to cellulitis of left finger, methicillin resistant staphylococcus aureus infection, open wound of left thumb without damage to nail, homelessness, contact with and suspected exposure to other viral communicable diseases, and presence of cardiac and vascular implant and graft. On 12/23/25 at 2:58 PM, via telephone, Resident R2 stated that twice in September, she was not given all required doses of her eye drops.On 12/30/25 at 12:30 PM, surveyor and V3 (Assistant Director of Nursing/ADON) reviewed Resident R2 and Resident R4's Medication Administration Record/MAR for September. V3 stated that daptomycin was not given to Resident R4 on 9/28/25, and on 10/1/25. She also stated that Resident R4 should not miss his antibiotic medication to ensure proper treatment of his infection. Resident R2's eye drop (brimonidine tartrate) was not signed on 9/12/25, and 9/13/25, and when MAR is not signed, that means the medication was not given.On 12/30/25 at 1:07 PM, via telephone, V46 (Nurse Practitioner/NP) stated that she has been in the facility since June 2024, she is familiar with Resident R4, and he was on daptomycin antibiotic intravenous/IV daily from 9/26/25 until 10/29/25. On 9/29/25, the pharmacy sent a memo that Resident R4's insurance will not cover daptomycin without a prior authorization which

she completed on 9/29/25, but it was still not approved so she ordered vancomycin as an alternative on 10/2/25 because that was when she was told that daptomycin was not approved. V46 stated Resident R4 should not miss his antibiotic because it could worsen his infection.On 12/30/25 at 2:47 PM V49 (Registered Nurse/RN) has been in the facility for eighteen years, she works 3pm-11pm shift mostly on the first floor.

Nurse should follow doctors order to maintain health of the resident. She stated the MAR should be signed once medication is given, if MAR is not signed it means the medication was not given. She stated she worked on 9/12/25 and 9/13/25 with Resident R2, she does not know why she did not sign the MAR on both days for Resident R2's eye drop (brimonidine tartrate). The potential effect of missing eye drops as ordered could increase Resident R2's eye pressure.Resident R2's Physician Order Sheet/POS active order as of 9/1/25 shows brimonidine tartrate ophthalmic solution 0.15%, instill 1 drop in both eyes every eight hours related to glaucoma.Resident R2's MAR showed missed doses of Brimonidine Tartrate on 9/12/25 at 6am, and on 9/13/25 at 10pm.Resident R4's Physician Order Sheet/POS active order as of 9/26/25 shows daptomycin intravenous/IV solution, one time a day for thumb cellulitis until 10/29/25.Resident R4's MAR showed daptomycin IV was not given on 9/28/25, 10/1/25, and 10/2/25 at 9am. Progress notes, Resident R4 was transferred to the hospital on [DATE REDACTED]. Registered Nurse and Licensed Practical Nurse Job description, document in part, Carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures. Policy on Administering Medication dated 9/2/25, document in part, medications are administered in a safe and timely manner, as prescribed.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet