Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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** R3 is a [AGE]
year-old female with a diagnoses history of partial paralysis following stroke, cognitive communication
deficit, recurrent major depressive disorder, anxiety disorder, adjustment disorder, end stage renal disease,
peripheral neuropathy, legal blindness, confirmed adult abandonment and neglect who was admitted to the
facility 06/07/2024.
Residents Affected - Some
On 12/09/2024 at 10:40 AM R3 stated she has inconsistently worn her medication patch and the nurses
have given inconsistent information on when she is supposed to have it applied. R3 stated she was told it
should be worn daily, then every three days, and once weekly and this is confusing. R3 stated they (facility)
don't always have her scheduled medications available. R3 stated she is supposed to receive an antianxiety
medication before going to dialysis to keep her calm and they were supposed to order it, but she just finally
received it the other day. R3 stated they have to go to two different carts to find her medications and this
shouldn't be that way. R3 stated she has had to go without her anxiety medication during dialysis at times
and just tries to deal with it. R3 stated when this happens, she does feel anxious during dialysis, and it
makes her want to discontinue receiving dialysis. R3 stated her right leg is like a big fat turkey leg and her
cardiologist was going to give her something for her foot as well but she hasn't received it. R3 stated she
doesn't have on compression hose. Observed R3's right leg swollen and without a Compression hose
applied. R3 stated the swelling comes all the way up her right leg.
R3's Current Physician Orders document an active order effective 06/20/2024 for Injection of 5000 units of
Heparin (Blood Thinner) subcutaneously every 8 hours for deep vein thrombosis (Blood Clot) prevention; an
active order effective 08/11/2024 for 50 MG Hydralazine (antihypertensive) tablet to be given by mouth four
times a day for hypertension hold if blood pressure below 110/60; an active order effective 10/20/2024 for
one 50 MG Lyrica (nerve pain reliever) capsule to be given by mouth at bedtime for neuropathy; an active
order effective 11/07/2024 for one 0.25 MG Alprazolam (antianxiety) tablet to be given mouth one time a
day every Monday, Wednesday, and Friday for anxiety give before dialysis; an active order effective
11/13/2024 for application (compression stocking) every morning/remove every evening one time a day; an
active order effective 11/22/2024 for completion of weekly skin check to ensure no new skin alterations are
present. (If new alteration is present completely new Skin Condition assessment); and an active order
effective 11/28/2024 for application of one Catapress TTS 3 (clonidine antihypertensive transdermal) patch
transdermally in the morning every Tuesday for hypertension and remove per schedule.
R3's November and December 2024 Medication Administration Record documents missing information for
Multiple scheduled medications including Heparin across multiple shifts on multiple days; missing
information for administration of scheduled Alprazolam on 11/25/2024 and 12/04/2024 and marked with a 9
referring to nurses notes; missing information for application of compression hose on multiple
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
145087
Printed: 05/15/2026
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
145087
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Oak Lawn
6300 West 95th Street
Oak Lawn, IL 60453
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
days in November and on 12/01/2024; missing information on Saturday 11/23/2024 for application of
antihypertensive Catapress TTS 3 (Clonidine) transdermal patch scheduled to be applied every Saturday
and missing information on Tuesday 12/03/2024 for application of antihypertensive Catapress TTS 3
(Clonidine) transdermal patch scheduled to be applied every Tuesday for with both entries marked with a 9
referring to nurses notes; missing information for administration of Lyrica on multiple days in November and
December 2024 and marked with a 9 referring to nurses notes in multiple entries; missing information for
administration of Hydralazine across multiple shifts on multiple days in November and from 12/03/2024 12/04/2024; and missing information for skin audits scheduled on Mondays in November and December
20204.
R3's current care plan documents she is at risk for bleeding/bruising related to antiplatelet medication use
with interventions including administer Medication as ordered she has potential for altered cardiac function
related to diagnosis: hypertension with interventions including monitor and document any edema;
medication as ordered; R3 has an alteration in comfort related to left heel pain with interventions including
administer pain meds and treatments as ordered; R3 requires the use of psychotropic medication
(Alprazolam) to assist with managing mood and behavior related to diagnoses of (anxiety) with targeted
symptoms/ behaviors of (refusal of care, and restlessness) with interventions including administer
medication as ordered; R3 has a diagnosis of/ history of coronary vascular accident (stroke) with right
residual effects with interventions including monitor for pain and provide pain medications, per physician
orders.
R3's Medical Practitioner progress note dated 11/12/2024 documents on exam patient has a right swollen
leg, with pain from her right hip radiating down to her right foot and pitting edema with plan for right lower
extremity including edema-monitoring; continue heparin (blood thinner), and apply compression hose as
appropriate.
R3's Medical Practitioner progress note dated 11/13/2024 documents patient is a [AGE] year-old female
patient past medical history of coronary vascular accident with right-sided partial paralysis, hypertension,
end stage renal disease and on hemodialysis, hyperlipidemia, and diabetes mellitus that that was seen to
establish care earlier in the week and was seen today to follow-up on complaints of right leg swelling and
pain. Patient continues to have edema.
R3's medication administration progress note dated 11/16/2024 and 11/28/2024 for her scheduled 50 MG
Hydralazine tablet to be given by mouth four times a day documents she was going to or in dialysis.
R3's medication administration progress note dated 11/19/2024, 11/20/2024, 11/21/2024, 11/24/2024,
11/27/2024, 11/29/2024, 12/02/2024, 12/04/2024 for her scheduled 50 MG Lyrica Capsule to be given by
mouth at bedtime for neuropathy was on order.
on order.
R3's medication administration progress note dated 11/23/2024 for her scheduled 50 MG Lyrica Capsule to
be given by mouth at bedtime for neuropathy documents a new script was needed and the pharmacy was
contacted for reorder.
R3's medication administration progress note dated 11/26/2024 for her scheduled 50 MG Lyrica Capsule to
be given by mouth at bedtime for neuropathy documents was awaiting pharmacy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145087
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
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
145087
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Oak Lawn
6300 West 95th Street
Oak Lawn, IL 60453
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R3's medication administration progress note dated 12/3/2024 for her scheduled (Clonidine)
antihypertensive transdermal patch to be applied transdermally in the morning every Tuesday for
hypertension and removed per schedule was on order.
R3's medication administration progress note dated 12/4/2024 for here scheduled 0.25 Alprazolam
(Benzodiazapine antianxiety) tablet to be given by mouth before dialysis once daily every Monday,
Wednesday, and Friday for anxiety was on order.
R3's Medical Practitioner progress note dated 12/4/2024 documents she states today that her Clonidine
(antihypertensive) patch was not being placed regularly and was just placed for the first time in a month.
She also states that she has not been given a compression stocking for her right lower extremity that was
ordered.
R3's progress notes from 11/23/2024 and 12/03/2024 do not include information regarding application of
Clonidine transdermal antihypertensive patch.
On 12/09/2024 at 2:29 PM V2 (Director of Nursing) stated if medications are not available when scheduled
to be given the nurse should call the pharmacy to order what is needed and medications should be ordered
before they run out. V2 stated she would reorder medications when they are down to a five-day supply. V2
stated R3's Hydrazaline and Lyrica medications can be pulled from the facility's Cubex (medication supply)
when needed and if it's not available there the physician should be called, and it should be charted why the
medication is not available. V2 agreed that missing medication administration documentation also makes it
difficult to determine if medications are being provided as ordered. V2 could not explain why R3 did not
have her compression hose on as ordered.
Based 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.
Findings include:
R1 a [AGE] year old, male admitted to the facility 11/05/2024 with diagnoses history of pulmonary
embolism and deep vein thrombosis, morbid obesity, Alcohol use disorder, diabetes, Hypertension, and left
humerus fracture.
On the (MDS) Minimal data Set assessment of 11/18/2024 section C the BIMS (Brief Interviewed Mental
status) score was 12/15.
On 12/05/2024 at 10:45AM R1 stated that he is not getting his Norco pain medication as ordered and
facility does not have medication in stock. R1 stated the facility is only giving half of his dose. R1 said, also
he is not getting some of his routine medication as ordered by the physician.
R1 physician order state Norco medication is ordered as needed 1-2 tablets as needed for pain. R1 needs
to request for the medication and let nurses know if he needs 1 or 2 tablets at a time. Electronic medication
administration records reviewed and R1 is getting pain medication every shift but routine medications
reviewed with concerns of multiple medication not signed as given during different days and different shifts
for the month of December of 2024.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145087
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
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
145087
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Oak Lawn
6300 West 95th Street
Oak Lawn, IL 60453
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
Medications not signed as given were:
Level of Harm - Minimal harm
or potential for actual harm
1.
Metformin 500mg 1 tab for diabetes in the evening dated 12/03/2024.
Residents Affected - Some
2.
Quetiapine fumarate 25mg 1 tablet for depression at bedtime dated 12/03/2024 and 12/05/2024.
3.
Eliquis 5mg 1 tablet scheduled 5:00PM dated 12/03/2024.
4.
Magnesium Oxide 500mg 1 tablet supplement scheduled 5:00PM dated 12/03/2024.
5.
Gabapentin 400mg scheduled 5:00PM dated 12/03/2024.
6.
Oxymetazoline nasal spray scheduled 5:00PM for allergy dated 12/03/2024 and 12/05/2024.
7.
Ammonium Lactate medicated lotion applies to lower extremities for dry skin scheduled 5:00PM dated
12/03/2024.
R1's Current Physician Orders document an active order effective 11/05/2024 for the medications not
signed as given for the month of December 2024.
R1's Medical Practitioner progress note dated 12/5/2024 documents that R1 takes Metformin for diabetes
and to monitor blood glucose level and for neuropathy R1 is taking Gabapentin and taking Eliquis for deep
vein thrombosis.
R2 is [AGE] year-old male admitted to the facility on [DATE]-[DATE] with diagnoses history of sepsis, end
stage renal disease on hemodialysis, hypertension, diabetes DM2, neuropathy, and anemia.
On the (MDS) Minimal data Set assessment of 11/18/2024 section C the BIMS (Brief Interviewed Mental
status) score was 15/15.
R2 is no longer in the facility and electronic medication administration records reviewed for the month
November and December 2024. There are concerns with multiple routine medications not signed as given
during different days and different shifts for the month of November and December 2024.
Medications not signed as given were:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145087
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
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
145087
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Oak Lawn
6300 West 95th Street
Oak Lawn, IL 60453
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
1-
Level of Harm - Minimal harm
or potential for actual harm
epoetin alfa injection 1000 units subcutaneous scheduled for 11/02/2024.
2-
Residents Affected - Some
insulin glargine 12 units bedtime scheduled for 9:00PM 12/03/2024.
3carvedilol 25mg 1 tablet scheduled for 4:00PM 12/03/2024.
4Gabapentin 100mg 1 capsule scheduled for 4:00PM 12/03/2024.
5hydralazine 100mg 1 tablet scheduled for 4:00PM 12/03/2024.
6isosorbide dinitrate 10mg 1 tablet scheduled for 4:00PM 12/03/2024.
7sevelamer HCl Oral 1 Tablet 800 MG scheduled for 4:00PM 12/03/2024.
R2's Current Physician Orders document an active order effective 10/18/2024 for the medications not
signed as given for the month of November and December 2024.
R2's Medical Practitioner progress note dated 11/14 /2024 documents that R2's takes Sevelamer for end
stage renal failure, Insulin Glargine for diabetes, Epoetin Alfa Injection for anemia, Gabapentin for
neuropathy and carvedilol and hydralazine for hypertension.
On 12/05/2024 and 12/09/2024 in separate interviews V10 (Licensed Practical Nurse/LPN) and V11 (Unit
Manager), both stated that if a medication is missing for a resident, nurses can remove from the emergency
convenience box and reorder missing medication. If a narcotic medication needs to be removed, nurses are
expected to call pharmacy to obtain a code to open the (emergency convenience box). If a medication was
not giving to a resident, nurses are expected to call and notify physician.
On 12/09/2024 at 12:24PM V2 (Director of Nursing) stated, nurses are expected to give medication and
sign out medication as they give them. If medications are not sign in the electronic medication
administration records, they were not given.
On 12/05/2024 at 3:39PM V1 (Administrator) presented Facility Policy titled Medication Administration
revision date 01/2024, which reads:
Guideline:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145087
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
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
145087
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Oak Lawn
6300 West 95th Street
Oak Lawn, IL 60453
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
18. Document as each medication is prepared on the MAR.
Level of Harm - Minimal harm
or potential for actual harm
22. If Medication is not given as ordered, document in the reason on the MAR and notify Health care
Provider if required.
Residents Affected - Some
26. If medication is ordered, but not present, check if was misplaced and then call the pharmacy to obtain
the medication, if available, obtain it from the contingency or convenience.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145087
If continuation sheet
Page 6 of 6
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the December 10, 2024 survey of ALIYA OF OAK LAWN?
This was a inspection survey of ALIYA OF OAK LAWN on December 10, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALIYA OF OAK LAWN on December 10, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.