Aliya of Evanston

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment and services for an indwelling urinary catheter for one resident (R1), resulting in a 4-hour period without nursing assessment or intervention when the catheter was not draining urine, leading to bladder distention and a traumatic bleeding insertion site injury that required immediate hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to ensure nursing staff possessed and demonstrated the competencies necessary to timely recognize, assess, and respond to a resident's acute change in condition and urgent call for help. This resulted in actual harm (significant bleeding requiring emergency hospitalization) for one resident (R1) who experienced a traumatic complication from an indwelling catheter insertion. R1 is a [AGE] year-old resident with a Brief Interview for Mental Status (BIMS) score of 15/15, and medical diagnosis including but not limited to paraplegia, complete; encounter for fitting and adjustment of urinary device; cystitis, unspecified with hematuria; hydronephrosis with ureteropelvic junction obstruction; acute kidney failure, unspecified; and calculus of kidney with calculus of ureter. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow its Residents Rights Policy by not ensuring the resident felt safe in the facility. This deficient practice affected one resident (R3) out of three residents reviewed for Resident Rights within a total sample of 3 residents. R3 is a [AGE] year-old male admitted to the facility on [DATE]. R3s medical diagnosis on the admission record are, but are not limited to, other cervical disc degeneration at C5-C6, mild intermittent asthma, type 2 diabetes mellitus, disorders of urethra, acute kidney failure, hypertension, hyperlipidemia, dementia with other behavioral disturbances, bipolar disorder with psychotic features, alcohol abuse, depression, and adult failure to thrive. On 12/31/2025 at 11:05AM, R3 was observed in his room, sitting upright in his room. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure and offer pneumococcal vaccinations to new residents within seven days. This failure applied to four (R16, R25, R32, and R45) of six residents reviewed for vaccinations.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to inform and obtain consents prior to the administration of psychotropic medication for two residents (R4 and R42) reviewed for psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered and follow the manufacturer's instructions for use. There were 25 opportunities with four errors resulting in a 16% (percent) error rate. This failure applied to two (R18 and R29) of four residents observed during medication administration.

Inspectors wroteBased on interview and record review the facility failed to follow discharges policy and change in resident condition policy by not informing the resident in advance of planned hospital transfer (Involuntary Petition), failed to obtain a physicians order for a transfer and failed to document the transfer in the medical record. This failure affects one resident (R1) of three residents reviewed for resident rights. Finding Include: R1 was admitted in the facility on 10/30/24. A [AGE] year old male resident with a BIMS of 15/15. R1 has diagnoses of but not limited to osteoarthritis of Right hip, Type 2 Diabetes, Morbid obesity, and Nicotine Dependence. R1 has a BIMS of 15 (Intact Cognition). On 5/6/25 at 11:32AM, R1 reported that he was sent out last April at 3:30AM, R1 stated he was sound asleep in his room when this night nurse woke him up and said he is going to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident from resident-to-resident verbal abuse. This failure affected two (R1, R2) of five residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident (R3) was free of abuse from (R2). This failure affected two of two (R2, R3) residents reviewed for abuse causing emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Survey Agency. This failure affected one (R3) of one resident reviewed for Abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse. This failure affected one (R3) of one resident reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to the resident right to privacy by staff not knocking on the door before entering a resident's room. This failure affected two (R1, R4) of four residents reviewed for privacy.

Inspectors wroteBased on observation, interview and record review the facility failed to discard expired opened medications from 2nd floor medication room. This failure has the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their 3 compartment sink policy by not submerging used utensils in the quat (Quaternary Ammonium Compounds) solution for 60 seconds and the facility failed to follow the Labeling and Dating Foods (Date Marking) Policy by not ensuring sandwiches were dated. This failure has the potential to affect all residents receiving nutrition from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor the temperature of the refrigerator unit in resident's room for four of four residents (R2, R3, R13, R16) reviewed for food safety in a sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to refer to appropriate state-designated authority for Level II PASARR (Pre-admission Screening and Record Review) evaluation and determination for one of five residents (R27) reviewed for PASARR in a sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's order on oxygen administration and to replace and safely store oxygen nasal cannula for two of two residents (R7, R35) reviewed for respiratory care in a sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow transmission-based practices for one of three residents (R204) reviewed for infection control in a sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure inhalers and insulin are dated when opened as manufacturer's recommendation for five of five residents (R2, R28, R35, R38, R40) reviewed for medication storage and labeling in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain hand hygiene during puree food preparation for seven of seven residents (R1, R4, R10, R21, R23, R25 and R35) reviewed for pureed diets in a sample of 12 residents. Findings Include: On 2/15/24 at 10:40AM after preparing starch, V8 (Chef) did not change her gloves, V8 was observed to open the oven, scooped out 8 portions of carrots and poured it in a blender. V8 then picked up the blender lid from the working table, covered the blender and proceeded to blend the carrots. After one minute, V8 opened the blender and proceeded to put her used left gloved hand into the blended carrots to check for smoothness. V8 did not change gloves prior to checking for smoothness. During an interview on 2/15/24 at 11:00AM, V8 stated that, she should have changed gloves before checking for smoothness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy is provided to residents receiving insulin administration for two of three residents (R5, R31) observed for insulin administration in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to report and initiate an investigation on an allegation of abuse for one of one resident (R3) reviewed for abuse in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents are free of significant medication errors for one (R31) of three residents observed for insulin administration in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility for three of three residents (R3, R35, R46) reviewed for arbitration in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to offer Influenza and Pneumococcal immunization to one of five residents (R198) reviewed for immunizations in a sample of 12.

Inspectors wroteBased on observation and interview, the facility failed to post daily staffing in a prominent place readily accessible to residents and visitors. This failure has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review facility failed to provide a hazard free environment by allowing resident to be exposed to a stationary floor block heater near resident's bed after a fall for 1 of 3 residents (R1) reviewed for accidents/hazards in the sample of three. As a result of this failure, R1 laid on the floor for an undetermined amount of time in contact with the heat source. R1 was emergently sent to the hospital, and treated for second-degree burns and pain management. This was identified as an immediate jeopardy. The immediate jeopardy began on 01/02/2024 when R1 fell and came in contact with a heat source as R1 was positioned between the bed and the radiator. The immediacy was removed on 01/09/2024. V1 (Administrator), V10 (Nurse Consultant/acting DON), and V13 (Regional Consultant) were notified on 01/04/2024 at 11:40 AM of the immediate jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a female resident was shaved and free of facial hair for one of four residents (R4) reviewed for Activities of Daily Living (ADLs) in the sample of eight.