Aliya of Palos Park

Inspectors wroteBased on interview and record review the facility failed to respect a resident's (R1) right by tampering with a camera in the resident's room. This failure affected one resident in a sample of 9. R1 is [AGE] years old with diagnosis not limited to: Metabolic Encephalopathy, Moderate Protein-Calorie Malnutrition, Acute Respiratory Failure With Hypoxia, Adult Failure To Thrive, Chronic Kidney Disease, Retention of Urine, Acute Cystitis Without Hematuria, Syncope and Collapse, Thoracic Aortic Aneurysm, Anemia, Obstructive And Reflux Uropathy, Constipation, Hypothyroidism, Dementia, Insomnia, Parkinson's Disease, Major Depressive Disorder. R1's 4/2/26 BIMS score is 00 (meaning the resident is not cognitively intact). R1's 11/10/25 care plan documents in part: R1's POA (Power of Attorney) prefers to have camera in her brother's room. On 5/8/26 at 12:38 pm R1 was observed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders pertaining to pressure ulcer prevention and failed to follow the facility's pressure ulcer policy. These failures affected one resident (R1) out of a sample of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform wound care in a manner that prevented contamination and failed to follow the wound care facility policy. These failures affected one resident (R1) of three residents reviewed for infection control. R1's face sheet documents in part the following diagnoses: Metabolic encephalopathy, dysphagia, protein-calorie malnutrition, unspecified dementia, cognitive communication deficit, local infection of the skin, cellulitis of the right lower limb, Parkinson's disease, and major depressive disorder. R1's minimum data set (3/11/2026) documents in part a brief interview of mental status (BIMS) summary score of 00, indicating that R1 has severe cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an incident to the nurse causing a delay in care for one resident (R3) out of five residents that sustained a scalp bruise and clavicle fracture. This failure resulted in R3 experiencing pain due to a fracture and bruise which was not treated until the following day.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and implement effective care plan interventions for one resident (R2) who was reviewed for falls. This failure resulted in R2 experiencing a right hip fracture as a result of a fall.

Inspectors wroteBased on interview and record review, the facility failed to follow their hospice policy and care plan for one (R2) out of three residents reviewed for mechanical lift for transfer from chair to bed. This failure resulted in R2 sustaining a laceration on her left leg that required R2 to be sent to the emergency room for suturing. The after-emergency room summary indicates that R2 was treated for laceration repair. The facility's final summary investigation indicates that R2 returned to the facility with 17 sutures.

Inspectors wroteBased on interviews and record review, the facility failed to conduct comprehensive assessment and implement wound care management for one (R1) of three residents reviewed for skin alteration. This deficiency resulted in R1's abrasion on the left great toe deteriorated to necrosis, gangrene, infection of left foot, and needs amputation.

Inspectors wroteBased on interview and record review, the facility failed to treat elevated blood sugars that were above the resident's baseline before it got to a critical level and the facility failed to put in any interventions for a resident experiencing vomiting and diarrhea to prevent dehydration. This affected two of three (R81, R84) reviewed for nursing quality of care. This failure resulted in R84 being sent to the hospital with a blood sugar level of 521 mg/dL and was diagnosed with uncontrolled diabetes and R81 being sent to the hospital to be treated for severe dehydration after being diagnosed with norovirus. Findings Include: R81 is an [AGE] year old with the following diagnosis: chronic obstructive pulmonary disease, nontraumatic intracerebral hemorrhage, chronic kidney disease, congestive heart failure, and peripheral vascular disease. [...]

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to follow the menu served to the residents. This failure affected 7 of 7 (R3, R9, R18, R84, R101, R103, and R105) residents receiving pureed diets in a sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address a resident's and a family's concern about response to call light wait times and failed to allow a resident to have personal refrigerator in at bedside while allowing another resident to have a personal refrigerator at the bedside. This affected two out of three residents (R15, R82) reviewed for resident rights. Findings Include: R15 is an [AGE] year old with the following diagnosis: heart failure, type 2 diabetes, and chronic atrial fibrillation. R82 is an [AGE] year old with the following diagnosis: Alzheimer's disease, dementia, and anorexia. On 04/22/25 at 11:21AM, R15 was interviewed while on the phone with R15's family member (V36). R15 and V36 reported it take 45 minutes or more for staff to answer the call light. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Call Light Response policy, by not placing the call light within reach. This affected one of three residents (R321) reviewed for accessible call lights. Finding Include: On 4/22/25 at 12:00pm to 12:08PM, R321 heard yelling Someone Please Help me. Observed R321 in his room, up on a Geri chair, on right side of the bed, foot side area. Call Light on bed, in upper head part of the bed, not within reach of R321. R321 was asking to be put back to bed and voiced out that he is looking for his dentures. On 4/22/25 at 12:10PM, confirmed with V4 (CNA/Restorative Aide) that R321's call light is not within R321's reach. V4 moved and placed the call light closer to R321, and within his reach. On 4/25/24 at 9:00AM, V2 (DON) stated that staff should place the call light within resident's reach. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to preserve one resident's privacy and dignity and obtain informed consent from the resident and resident's POA (power of attorney) to reside in a semi-private room in which the roommate has constant video monitoring. This failure affected two resident (R71, R77) out of three reviewed for privacy in a sample of 37.

Inspectors wroteBased on interviews and records reviewed the facility failed to include intervention prevent or reduce the risk of skin breakdown. for one of three (R1) residents reviewed for plan of care interventions for skin breakdown, failed to follow their policy to complete a comprehensive skin assessment on one resident (R1) with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present. This failure affected 1 of 4 residents in a sample of 37 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interviews and records the facility failed to follow their policy to complete a comprehensive skin assessment on one resident with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present, failed to ensue effective interventions were in place, and failed to ensure low air loss mattress was used per manufactures recommendations. This affected two of four residents (R1, R325) reviewed for pressures sore preventions and effective interventions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to obtain and document a diagnosis in the physician orders for an indwelling catheter for one resident (R70) out of three reviewed for indwelling catheters in a sample of 37.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to document accurate meal intakes. This affected two of three residents (R12 and R51) reviewed for nutrition in a sample of 37.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their physician services policy and ensure the attending physician conducted face-to-face visits within the first 30 days of admission/re-admission and/or at least once every 60 days. This affected two of three (R12, R51) residents reviewed for care managed by a physician in a sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to assist a resident with a degenerative eye disease in obtaining transportation to an outside retinal specialist appointment. This affected one of one (R27) residents review for transportation in a total sample of 37. Findings Include: R27 is an [AGE] year old with the following diagnosis: macular degeneration. On 4/22/25 at 10:22AM, R27 stated R27 had an appointment for an eye appointment the first week of April but had to cancel it because the cost of transportation was $270. R27 denied being offered to see the in-house eye doctor. R27 reported R27 would be willing to see the in-house eye doctor because R27 wants to preserve R27's vision for as long as possible. On 4/24/25 at 12:15PM,V18 (Health Information Management Director/Appointment Scheduler/Transportation) stated V18 had an appointment on 4/8. [...]

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their policy and complete quarterly psychotropic assessments and assess for or attempt a Gradual Dose Reduction for one resident on an antidepressant. This failure affected one of one (R47) resident in a sample of 37 reviewed for psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to give prednisolone acetate ophthalmic suspension 1% (steroid eye drop) and Midodrine 5mg tablet (medication that increases blood pressure) as prescribed. This affected two of six resident (R320, R27) reviewed for medication administration in a total sample of 37. Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/23/25 at 8:37AM, V25 (Nurse) took R320's blood pressure and it was 83/39 (low). On 4/23/25 at 9AM, V25 administered all morning medication except Midodrine 5mg tablet. V25 stated medication should be stocked in the pyxis by pharmacy or ordered by the nurse when the medication is low within three to four pills left. V25 reported pharmacy will deliver the medication automatically when it is due to be delivered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove an expired medication from a medication cart, failed to store two bottles of a medication in a refrigerator that has instructions to store the medication between 36-48 degrees Fahrenheit, and failed to dispose of a controlled medication after it was discontinued during the review for medication storage in a total sample of 37. Findings Include: R3 is a [AGE] year old with the following diagnosis: congestive heart failure and metabolic encephalopathy and on hospice. R38 is a [AGE] year old with the following diagnosis: senile degeneration of the brain and arteriovenous malformation of the digestive system. On 4/23/25 at 9:10AM, the Oak Wing Medication cart on the 2 North unit was reviewed by with V26 (Nurse). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their transmission based precautions policy by two staff not wearing a gown or gloves in a contact isolation room for one resident (R320) reviewed for infection control in a total sample of 37. Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/22/25 at 12:20PM, PPE (Personal Protective Equipment) cart/drawer present by R320's room, signage for Contact Isolation posted at resident's door. V6 (CNA) entered contact isolation room with meal tray. Did not put on PPE. V6 only used surgical mask, and no gloves and no gown, no handwashing observed prior to entering the room. Touched items in the bed side table and placed phone from beside cabinet to overhead table, as per resident's request. Also assisted resident in cutting meal. V6 exited the room and used hand sanitizer. [...]

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to complete a comprehensive metabolic panel for one of three resident (R1) reviewed for physician orders.

Inspectors wroteBased on interview and record review the facility failed to implement effective fall intervention to prevent a resident from falling which resulted in resident walking by herself, falling, and sustaining a left hip fracture. This failure affected 1 resident (R2) of 3 residents reviewed for falls in a total sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to supervise one resident while sitting in the dining room unattended who was identified as a high fall risk and has a diagnosis of Dementia, syncope, and a history of falls. This failure resulted in R401 having an unwitnessed fall from her wheelchair sustaining a left hip fracture. The facility also failed to utilize a leg rest during a transport for a wheelchair bound resident. This failure resulted in R61 having a fall from the wheelchair sustaining a right forehead hematoma. These failures affected two of three residents reviewed for falls in a total sample of 26. Findings Include: R401 was diagnosed with Dementia, Syncope and Collapse. Minimal data set Section GG (functional abilities and goals) dated 3/31/24 documents: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system to track requests for diagnostics services to ensure timely x-ray services are provided to residents. This failure resulted in R5 being transported to the hospital after waiting over 30 hours for x-ray service and being diagnosed with multiple rib fractures for one of one reviewed for diagnostic services in a total sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Sanitizing Guidelines and Manufacturer's Instructions by not sanitizing a knife and cutting board for 1 minute. This failure has the capacity to affect 104 residents receiving an oral diet at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure mail was delivered to residents on Saturdays for seven out of seven residents (R5, R11, R21, R40, R53, R76, R80) reviewed for residents' rights in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to notify family of a resident's change of condition for one of three residents (R251) reviewed for notification of change in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident identified as at risk for abuse was free from misappropriation of resident property by not providing a secure location for R86 to store his money. This affected one of three (R86) residents reviewed for misappropriation of funds. This failure resulted in R86 having four hundred dollars stolen while he was in the facility. This failure affected 1 of 3 reviewed for misappropriation of resident's funds in a total sample of 26. Findings Include: R86 was diagnosed with aphasia following a cerebral infraction. Minimal data set section C (Brief interview for mental status) dated 2/23/24 documents: memory/recall ability: resident (R86) was normally able to recall location of own room, staff names/faces and that they are in a nursing home/hospital swing bed. Cognitive skill for daily decision making documents: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not immediately reporting a bruise of unknown origin to the immediate supervisor or the administrator. This affected one of three (R17) reviewed for injury of unknow origin in a total sample of 26.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure one resident's airway (R4) with a tracheostomy was free of obstruction by not removing the inner cannula during Cardiopulmonary Resuscitation (CPR) attempts. This affected one of three (R4) residents reviewed for emergency management. This failure resulted in R4 remaining in respiratory distress and the facility was unable to locate a spare trach tube to provide emergency oxygen during a Code Blue. R4 was transported to the local emergency room and pronounced deceased on the same day. The Immediate Jeopardy began on [DATE] when R4 developed respiratory distress and staff were unable to locate inner trach tube to provide oxygen and clear R4's airway. V7 (Administrator) was notified on [DATE] at 10:54 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders and implement wound care treatment for a resident with a noted stage 2 pressure sore. This affected one of three residents (R1) reviewed for pressure sores. This failure resulted in R1's wound worsening requiring debridement and progressing to a stage 3.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure that staff working followed the standard of care during a code blue by establishing an airway and turning on the oxygen tank to provide needed oxygen. This affected one of three residents (R4) reviewed for oxygen use during a code blue.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders and administer phenobarbital (Anti-Seizure) as ordered. This failure affected one of three (R2) reviewed for physician orders. This failure resulted in R2 missing 7 scheduled doses of phenobarbital, subsequently developing seizures activities requiring R2 to be sent the local hospital for treatment of seizures.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure census reports were accurate when notifying an external entity (Age Options) of new admission to the facility, discharges out of the facility, and death of residents. This failure affected 7 residents reviewed in a sample of 98 residents.

Inspectors wroteBased on interviews and records reviewed the facility failed to have an effective plan to monitor/supervise resident identified to be high risk for falls This affected one of three residents (R1) reviewed for falls and fall prevention. This failure resulted in R1 falling from bed and sustaining a non-displaced transverse fractures demonstrated on the right side at the C6 and C7 levels.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to follow their policy and plan of care, by not repositioning a cognitively impaired, incontinent, and dependent resident with a stage 3 buttock pressure ulcer for over 2 hours. This failure affected one of three residents reviewed for pressure sore prevention nterventions.

Inspectors wroteBased on interview and record review the facility failed to have an (IP) Infection Preventionist with the required specialized Infection Prevention Control training beyond the initial professional training and education. This failure has the potential to affect all 98 residents listed on the facility census. Findings Include: On 2/22/23 at 3:30 PM V22 (Infection Preventionist) said I took the IP training that was recommended by corporate. It was Infection Control training. That was all the IP training that I have completed. The facility presented a certificate from InfectionControlsTraining.com for V22. [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure that medication was administered as ordered by the physician for 4 of 4 residents (R15, R35, R56, R200) and facility failed to prevent significant medication errors for 1 of 4 residents (R56) reviewed for medications in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dignity was maintained by not providing incontinence care in a timely manner for 1 of 4 residents (R13), the facility also failed to ensure a privacy bag was provided for urinary catheters for 2 of 2 resident (R70, R89) reviewed for resident's rights in a sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the call light was within reach for two residents (R30 and R82) reviewed for call light in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to provide the prescribed wound treatment for one (R92) of one resident reviewed for other skin conditions in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to provide the prescribed pressure ulcer treatment for one (R89) of one resident reviewed for pressure ulcer in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a splint to prevent contractures on one resident (R82) out of one resident reviewed for splints in the sample of 25. Findings Include: On 02/21/23 at 3:15 PM, surveyor observed R82 with V4 (Director of Therapy). V4 asked R82 to open his right hand which was a closed fist, but he could not. V4 assisted R82 to open his right hand. V4 said that it was not been brought to her attention that R82 cannot open his right hand by himself. On 12/22/2023 at 10:49 AM, V11 (Restorative Nurse) said that she was aware that R82 cannot open his hand by himself. V11 said that R82 is on range of motion, and bed mobility program. V11 said that a hand splint to prevent contractures should have been ordered before yesterday 2/22/2023 and that it was initiated. On 02/23/2023 at 11: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to handle oxygen safely for one (R7) of one resident observed for oxygen therapy in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors related to antibiotic administration for 1 of 4 residents (R56) reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate transmission-based precautions for two (R88, R147) of two residents observed for transmission-based precautions in a sample of 25.