Aliya of Oak Lawn

Inspectors wroteBased on interviews and record review, the facility failed to update R2's comprehensive wound care plan when new wounds were identified on May 13, 2026. This failure affected one resident (R2) in a sample of four residents reviewed. On 6/9/2026 at 10:43 AM, R3 stated that no complaints regarding staffing and reported that staff are consistently available to assist her with her care needs, including providing assistance with changing her dressing. R3 further stated that she previously had wounds on her left leg that have since healed. On 6/9/2026 at 10:48 AM, R4 stated that he has been residing at the facility for approximately one month and said that everything has been going well thus far. R4 stated that he was admitted with a wound on his right foot and reported that the wound care team provides treatment on a daily basis. R4's right foot wound was observed dressed appropriately. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were administered as ordered by the physician for three of three residents (R2, R3 and R4) reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Agency of the initial and final report after one resident (R2) was emergently transferred to a local hospital and diagnosed with an acute and displaced right femoral neck fracture.

Inspectors wroteBased on interview and record review, the facility failed to follow their dialysis policy by not communicating to their IN -HOUSE Dialysis Company that a new resident who was diagnosed with acute kidney failure and dependent on renal dialysis was admitted into the facility. This affected one of three residents (R159) reviewed for hemodialysis. This resulted in R159 missing treatments, subsequently R159 central venous catheter clotted requiring two hours of anti-clog therapy and having to remain in the dialysis chair for a total of four hours and forty-six minutes which caused R159 to have extreme leg pain.

Inspectors wroteBased on interview and record review, the facility neglected to follow established clinical protocols, manufacture's guidance, internal training guidelines, and to follow their policy and procedures outlined in the Subacute Rehabilitation (SAR) Long-Term Acute Care (LTAC) Ventricular Assist Device (VAD) Training Manual, Heart Failure (HF) Left Ventricular Assist Device (LVAD) HF-LVAD HeartMate-3 Patient Guide, VAD Emergency Guide, LVAD Pocket Reference Guide. This affected one of one resident (R1) reviewed for providing services for a resident utilizing a LVAD. This neglectful practice resulted in R1 LVAD batteries not being monitored or changed when reached 50% capacity, R1 batteries depleted the pump stopped, R1 sent to hospital for cardiac arrest, R1 expired. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide appropriate, person-centered care and treatment to ensure the highest practicable physical, mental, and psychosocial well-being of 1 of 1 resident's (R1) reviewed with a Left Ventricular Assist Device (LVAD), who was found unresponsive. The facility failed to follow its own emergency response protocol, resulting in a failure to identify that R1's LVAD system had stopped functioning due to depleted batteries, contributing to cardiac arrest and subsequent death. The Immediate Jeopardy which began on [DATE] when the facility failed to follow their policy/practice/protocol to check the Left Ventricular Assist Device for functioning, if the device is running during an emergency when a resident R1 was observed unresponsive contributing to cardiac arrest and subsequent death. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their baseline care plan policy and develop an individualized baseline plan of care to include physician orders for a left ventricular assist device for a resident, This affected one of two residents (R2) reviewed for care plans and LVAD. R2 was admitted to the facility on [DATE], R2 face sheet shows diagnosis of chronic systolic congestive heart failure, atrial fibrillation, and presence of heart assist device. R2 facility census shows admission date 09/12/2025 and discharge date [DATE]. R2 progress notes show R2 sent to hospital for change in condition on 09/15/2025. R2 third eye heath note dated 09/13/2025 at 10:09am denotes in-part patient name-R2. [...]

Inspectors wroteBased on interview, record review the facility failed to follow professional standards of care for residents requiring LVAD (Left Ventricular Assist Device). This affected two of two residents reviewed for LVAD. This failure resulted in the facility failure to assess and monitor the battery level for R1 LVAD and failure to intervene when the batteries depleted and failed to ensure R2 had physician orders in place in the medical record. 1. R1 face sheet diagnosis of encounter for surgical after care following the circulatory system, unsteadiness on feet, type 2 diabetes mellitus, ventricular tachycardia, presence of heart assist device, cognitive communication deficits, COPD, acute and chronic congestive systolic heart failure. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their facility assessment and ensure that staff received in-service and training to provide care and service for residents with a left ventricular assist device. This affected two of two resident reviewed ( R1, R2). 1. R1's face sheet indicates diagnoses of encounter for surgical after care following the circulatory system, unsteadiness on feet, Type 2 Diabetes Mellitus, Ventricular Tachycardia, presence of heart assist device, cognitive communication deficits, COPD, Acute and Chronic Congestive Systolic Heart Failure. R1's MDS dated [DATE] shows BIMS score of 11 (cognitive deficits).2. R2 was admitted to the facility on [DATE], R2 face sheet shows diagnoses of Chronic Systolic Congestive Heart Failure, Atrial Fibrillation, and presence of heart assist device. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and prevent resident-to-resident sexual inappropriateness. This affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R2 touching, groping and fondling R1 inappropriately resulting in R1 feeling helpless, scared, tearful and feeling uncomfortable. Findings Include:R1 was admitted to the facility with diagnoses of reduced mobility and functional quadriplegia. R1s Minimal data set (MDS) section C (cognitive patterns) dated 7/14/25 documents: a score of fifteen which indicates cognitively intact. Section GG (functional abilities) documents: R1's is dependent on staff to roll left to right, sit to lying and lying to sitting on the side of bed. R1's care plan initiated on 07/13/2025 documents: ABUSE/NEGLECT: [...]

Inspectors wroteBased on interview and record review the facility failed to follow its abuse policy by not reporting an allegation of abuse to the regulatory state agency within 24 hours. This affected two of three residents (R1, R2) reviewed for abuse policy. Findings Include:R2's Behavior note created on 8/18/25 at (12:49) documents: Behavior Description: Inappropriately touching another resident. Behaviors: resident (R2) observed inappropriately touching a resident (R1). Nursing note dated 8/18/25 documents: Writer heard a resident (R1) yell out for help, writer got up to go to the yelling. Writer observed above resident (R2) in his wheelchair bending and reaching over to a resident (R1) in bed. Resident (R2) being petitioned to the hospital for inappropriate sexual behavior towards his peer. [...]

Inspectors wroteBased on interview and record review, the facility failed to effectively monitor and supervise a resident with a diagnosis of dementia from wandering into another resident's room without permission and sexually touching another resident. This affected two of three residents (R1, R2) reviewed for supervision of resident with dementia. Findings Include:On 8/23/25 at 2:45pm, R1 who was assessed to be alert and oriented to person, place and time, said he was in bed when R2 entered his room via wheelchair. R1 said, R2 rolled on the side of his bed, stopped his wheelchair, stood up, lifted R1's gown and ripped opened R1's adult brief. R1 said, R2 put his hand around his penis and started rubbing it. R1 said, he was scared, he yelled for help and R3 saved his life. R1 said, he felt uncomfortable. R1 said, he does not have sexual activities with men. R1 said, he is not like that. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its policy and provide showers/complete bed bath for residents requiring moderate assistance to total dependence of staff for bathing and failed to remove a bedpan from underneath a resident for approximately 35 minutes. This affected four of four residents (R1, R3, R4, and R7) out of 4 reviewed for ADL (Activities of Daily Living) care

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were available to meet the needs of its residents. This affected four of four residents (R1, R3, R4, and R7) and rooms on the east and northeast unit.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its policy and ensure that residents had physician orders for medications stored at the bedside and were assessed for self-administration of medications. This affected two of three residents (R1, R7) reviewed for self-administration of medications

Inspectors wroteBased on observation, interview, and record review the facility failed to have a functioning call light system and failed to develop an effective plan for the residents to call for assistance on the North unit, this affects 28 of 28 resident (R1, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, and R30) reviewed for functioning call system.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the resident food preference for one of 3 residents (R2) reviewed for food preference not being followed.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to provide bathroom/toileting assistance to 2 (R1 and R8) dependent residents. This failure affected 2 of 3 residents reviewed for toileting assistance.

Inspectors wroteBased on interviews and records reviewed the facility failed to monitor and provide supervision during a smoking break. This affected two of three residents (R2, R3) reviewed for supervision. This failure resulted in a resident to resident-to-resident altercation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Label and date opened food in the freezer, 2. Follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net and failing to use a beard restraint while in the kitchen, 3. Maintain infection control by placing a pair of oven gloves and a package of gravy inside clean and sanitized pots in the food preparation area and clean a whisk used during meal preparation, 4. Follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch, and 5. Follow their policy on maintaining the proper sanitation level in the three compartment sink. These failures have the potential to affect all 151 residents who receive oral meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the pharmacy policy by not noting and implementing open date labels for five of five (R148, R410, R22, R24, R131) residents reviewed during medication storage and labeling task in the sample of 31.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for medication administration by not ensuring residents received medication and treatments as ordered by the physician. This failure applied to three of three (R1, R2, R3) residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for urinary catheter and urinary catheter care; the facility also failed to implement care plan interventions related to urinary catheter care and monitoring, including monitoring for signs of urinary tract infection symptoms. This failure applied to one of three (R11) residents reviewed for catheter care and resulted in R11's emergent hospitalization and subsequent diagnosis of septic shock requiring intensive care unit admission.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from being physically abused by another resident. This failure applied to two of two (R1, R2) residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from mental abuse and intimidation by staff. This failure affected three of three residents (R2, R7 and R8) living in the facility at the time of this survey and reviewed for mental abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's phone was not stolen by a visitor of the facility. This failure applied to one (R3) of three residents reviewed for misappropriation of property.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities to meet the need/interest of one resident (R4) who was bed bound with deformities. This failure affected one resident in a total sample of twenty-five residents.

Inspectors wroteBased on interview, and record review the facility failed to follow their policy and resident care plan related to skin care and activities of daily living for one dependent resident (R4) to keep skin clean and failed to follow doctors' orders to administer three residents (R2, R16, R17) their prescribed medication. These failures affected four of four residents reviewed for improper nursing care in a sample of twenty-five.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy and report an allegation of physical abuse immediately. This affected one of three residents R1 reviewed for reporting allegations of abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely incontinence care for 1 of 3 dependent resident, R13 in a sample of 28 reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention interventions to a resident who is at high risk and with history of falls. This deficiency affects one (R20) of three residents in the sample of 28 reviewed for Fall Prevention Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to sign the shift-to-shift controlled substance count sheet acknowledging that actual count of controlled substances and count sheet matches the quantity documented. This deficiency affects one (North Unit Medication cart 1) of four medication carts reviewed for Handling, Storage and Record Keeping of Controlled Substance.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and document medication refrigeration temperature and failed to place date on tuberculin purified protein after opening as manufacturer recommendation. This deficiency affects both two medication rooms (West and North unit) reviewed for Safe Medication Storage.

Inspectors wroteBased on interview and record review, the facility failed to offer influenza, Pneumococcal and COVID immunizations as required to three of five residents (R21, R107, and R133) reviewed for immunization in a sample of 28 residents.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by staff. This failure applied to one of three (R3) residents reviewed for sexual abuse that resulted in R3 being sexually abused by a facility RN (Registered Nurse). The Immediate Jeopardy began on 03/02/24 when R3 was sexually abused by a facility Registered Nurse (V14). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/07/24 at 1:15PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 3/11/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interviews and record review, the facility failed to follow their policy and procedures for preventing residents from further potential abuse by staff, after an allegation of staff to resident sexual abuse was made. This failure applied to one of three (R3) residents reviewed for sexual abuse investigation procedures and has the potential to affect the 126 residents currently in the facility. The Immediate Jeopardy began on 03/02/24 when R3 was sexually abused by a facility Registered Nurse (V14). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/07/24 at 1:15PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 3/11/24, but noncompliance remains at Level Three because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective and individualized fall interventions for a resident assessed to be at high-risk of falling. This failure affected one (R6) of one resident reviewed for falls which resulted in R6 requiring urgent hospitalization for pain, and subsequently being diagnosed with a fracture of the right hip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an available supply of pain medication as ordered for a resident. This failure applied to one of one (R6) resident reviewed for pain and resulted in R6 experiencing uncontrolled pain, rating 10 out of 10, related to a fracture of the right hip sustained while living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide and maintain an adequate amount of nursing staff to care for 33 residents who required minimal to moderate assistance on the short-term rehabilitation unit of the facility. This failure applied to one (R9) of one resident reviewed for nursing care and has the potential to affect 33 residents currently on the rehabilitation unit of the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide and document timely incontinence care for a resident dependent on staff for assistance with ADLs (activities of daily living). This failure applied to one of one (R9) resident reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by failing to assess residents for abuse risk and failed to develop an abuse care plan for these residents. This failure affected five (R9, R10, R11, R13 and R16) of five residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their room change/transfer policy and procedures by not ensuring a resident's representative was notified of a room change and not obtaining the resident representative's permission to change the resident's room. This failure applied to one of three residents (R19) reviewed for resident's rights.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for assistance with activities of daily living by not ensuring a dependent resident who is blind received assistance with grooming her hair, dressing, incontinence care, being transferred out of bed, and storing her clothing and belongings in an orderly manner. This failure applies to one of three residents (R19) reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their fall prevention policy by not implementing fall preventative measures per the president's plan of care. This failure applied to two (R1, R2) of six residents reviewed for accident/hazards.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for pain management by not examining a resident's newly reported pain in a timely manner, not performing, and documenting a pain assessment for newly reported pain, and not ensuring a resident received pain management as needed. This failure applied to one of three residents (R19) reviewed for pain management.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their dental care policy and procedures by not ensuring a resident received routine dental services to meet their needs. This failure applies to one of three residents (R19) reviewed for dental care.

Inspectors wroteBased on observations and interviews, the facility failed to follow their policy and procedures for ensuring resident care equipment is in safe operating condition by not identifying a blind resident's wheelchair was in disrepair and in need of replacement. This failure applied to one of three residents (R19) reviewed for resident rights.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to adequately monitor a resident with advancing dementia and history of wandering, recent episodes of wanting to leave the facility unauthorized, and without facility staff knowledge. This affected one of three residents (R1) reviewed for supervision and monitoring. This failure resulted in R1 leaving the facility unauthorized, being found walking and falling on the sidewalk next to a busy street. A bystander notified EMS (emergency medical services) 911 for police assistance for R1. R1 was transported to the local hospital for further treatment. R1 sustained a laceration and nasal fracture. The immediate jeopardy started on 10/10/2023. V1 (interim administrator) and V12 (administrator) were notified on 10/24/2023 of the immediate jeopardy. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to monitor, re-evaluate the treatment plan for a resident's facility acquired wound, and revise treatment to reduce the risk of worsening or developing an infection. This affected one of three residents (R11) reviewed for wounds. This failure resulted in R11 developing a wound on top of right second toe on 9/11/23. On 9/22/23, R11 was admitted to the hospital with a wound infection with bone involvement requiring amputation of the toe.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their skin care prevention policy. Facility failed to identify a skin alteration upon readmission in the facility and failed to have appropriate treatment for a pressure injury skin alteration. This affected one of three residents (R4) reviewed for pressure ulcer. This failure resulted in R4 being admitted to the facility with unassessed stage 2 pressure ulcer in the sacrum area on 8/25/23 R4 went without treatment and R4's stage 2 progressed into an unstageable by 9/5/23. Findings Include: R4 readmitted to the facility on [DATE]. Reviewed Admission/readmission Evaluation dated 8/25/23: there is no documentation for any skin alteration in sacral and/or coccyx area for R4. Hospital record dated 8/23/23, reads in part: Coccyx stage 2 pressure injuries measures 4.0cm x 3.0 cm x 0.1 cm. scant serosanguinous drainage. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident's family or representative of wounds identified and/or update family on deteriorated wounds. This affected two of three (R10, R11) residents reviewed for notification of change.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain complete and accurate medical records for two residents (R10 and R11) out of three reviewed for accuracy of documentation.

Inspectors wroteBased on interviews and records reviewed the facility failed to report an allegation of abuse for 1 (R1) who reported to staff she was drugged and raped. This failure affected one of three (R1) residents reviewed for investigation of abuse allegations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who requires extensive assist of staff with ADLs (activities of daily living) received incontinence care. This applied to one (R3) of three residents reviewed for activities of daily living in the sample of five.

Inspectors wroteBased on observation, interview and record review the facility failed to implement hand hygiene during wound and incontinence care, failed to use PPE (Personal Protective Equipment), and failed to complete a resident COVID surveillance assessment. This deficiency affects all 6 (R1, R20, R63, R72, R135 and R136) residents in the sample of 19 reviewed for infection Control.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep call lights within resident's reach for two (R68, R335) of six residents reviewed for call lights in a sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident's advance directive is reflected in the resident's medical record for one (R60) of five residents reviewed for advance directives in a sample of 19.

Inspectors wroteBased interview and record review, the facility failed to develop and implement care plans for residents on antibiotic, anticoagulant treatment, and update a care plan for a resident with COVID infection for three (R1, R60, R335) of four residents reviewed for care plans in a sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician order to apply TED (thromboembolic deterrent) hose for one (R335) of one resident reviewed for edema management in a sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions for pressure ulcer prevention were implemented and failed to apply heel boots for 1 of 4 residents (R13) reviewed for pressure ulcers in a sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the indwelling catheter below the resident's bladder to prevent back flow of urine into the bladder. This deficiency affects one (R20) of three residents in the sample of three reviewed for urinary catheter management.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders in administration of oxygen to a resident. This deficiency affects one (R20) of three residents in the sample of 19 reviewed for oxygen management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications from the North side medication room for one (R20) of one resident reviewed for medication storage and labeling in one of four medication rooms observed.