Central Nursing Home

In the surveyor’s words

From the most serious findings on record at Central Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 20, 2024

  Based on observation, interview, and record review the facility failed to properly monitor and supervise a resident (R1) with known risk of elopement. This failure resulted in R1 eloping from the facility [DATE]. R1 was found deceased in an abandoned building one month later by South Suburban police on [DATE]. This was identified as an Immediate Jeopardy began on [DATE]. On [DATE] at 11:36am, V1 (Administrator) was notified of the Immediate Jeopardy. The facility presented an abatement removal plan on [DATE] at 6:57pm and was not approved. The facility submitted a revised abatement plan and was approved on [DATE] at 12:36pm. Findings include: Facility reported incident dated [DATE] documents at 6:30pm, alarm was activated from the first-floor South exit. […]

• Actual harm, isolatedF600Jul 6, 2026

  Based on observation, interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse. This failure affects two (R1, R5) residents out of five residents reviewed for abuse in a sample of five. As a result of this failure, R2 verbally threatened R1 and R5 on separate occasions, and R2 physically hit R1 on 06/28/2026 resulting in R1 sustaining a head laceration, multiple contusions, and closed fracture of nasal bone.Findings include:On 07/01/2026 at 10:45 AM, R1 stated I feel 100% safe now that he (R2) is not here. R1 stated this happened this past Sunday June 28th, 2026. […]

• Actual harm, isolatedF609Jul 6, 2026

  Based on interview and record review, the facility failed to report and investigate abuse allegations for two (R1, R5) of five residents reviewed for abuse in a sample of five. As a result of this failure, R2 verbally threatened R1 and R5 on separate occasions, and R2 physically hit R1 on 06/28/2026 resulting in R1 sustaining a head laceration, multiple contusions, and closed fracture of nasal bone.Findings include:On 07/01/2026 at 10:45 AM, R1 stated I feel 100% safe now that he (R2) is not here. R1 stated this happened this past Sunday June 28th, 2026. The harassment started in May 2026, I (R1) was at the counter at the nurse's station, he (R2) was standing by the nurse's station, next to me, talking verbally abusive oh you want it, you think you run it here, you are a b****. […]

• Actual harm, isolatedF600May 29, 2026

  Based on observation, interview and record review, the facility failed to (a) ensure one resident (R16) was free from abuse from a staff member; (b) failed to ensure that a resident (R2) was free from abuse from another resident. This failure resulted in R16 enduring psychosocial abuse and harm; R2 being confronted by another resident (R14) who had a box cutter in their possession, resulting in R2 leaving the facility against medical advice (A.M.A). Findings include: a. On 5/26/26 at 12:18 PM, R16, said this Saturday I got a visitor, my sister. We were going out on pass. I got it approved with V2 (Director of Nursing). My sister talked to someone about going out. I'm on red pass because I was late coming back from out on pass. […]

• No harm, potential for more than minimal, widespreadF584May 29, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate and clean linen for residents in the facility. This failure has the potential to affect all 209 residents residing in the facility. Findings include: On 05/27/2026 at 10:04AM, surveyor located on the fourth floor of the facility observes one linen cart in the hallway. The following items were observed on the linen cart: 0 wash cloths, 0 bath towels. V10 (Certified Nursing Assistant/CNA) states there is only one linen cart on the fourth floor. V10 states there is a drawer at the nurses' station where she keeps extra towels and linen for residents because the linen cart is not always fully stocked. […]