Health inspection·April 3, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based 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 Residents Affected - Few Findings include: On 3/29/25 at 10:16 AM, R7 was observed to have a bottle of refresh eye drops on bedside table. R7 stated that the nurses have been administering this medication to him twice a day since his admission to this facility. R7 stated that he is not able to self-administer this medication. R7 stated that he is waiting for the nurse to administer eye drops. On 3/29/25 at 3:00 PM, R1 was observed to have a container of oral antidiarrheal medication on bedside table. R1 stated that R1 has diarrhea intermittently due to medical condition and has asked the nurse to have medication ordered. R1 stated that when R1 asks for this medication, the nurse informs R1 that the facility does not have any antidiarrheal medication. R1 stated that R1's family member brought in this medication so R1 can self-administer when needed. On 3/29/25 at 11:05 AM, V2 DON (director of nursing) stated that before a resident can self-administer medications, a skill assessment needs to be done. V2 stated that if the resident's BIMS (brief interview of mental status) is high enough and if the resident can demonstrate how to administer medication safely to themself, a physician order would be obtained. R7's BIMS, dated 3/27/25, notes R7's score is 15 out of 15. R7 is cognitively intact. R7's POS (physician order sheet) does not note an order for refresh eye drops, an order to self-administer or store these eye drops at bedside. R1's BIMS, dated 2/20/25, notes R1's score is 12 out of 15. R1's cognition is moderately impaired. R1's POS does not note a current order for loperamide (antidiarrheal) oral medication. There is no order to self-administer or store this medication at bedside. This facility's self-administration of medications by residents' policy, undated, notes an interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment, in part: the resident is instructed in the medication, the resident is requested to read the label, and demonstrate the steps involved in self-administration of the medication. A further assessment of the safety of bedside medication storage is conducted. If the interdisciplinary team Page 1 of 6 145087 145087 04/03/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0554 approves the resident to self-administer and store medications at bedside, a physician order will be obtained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145087 Page 2 of 6 145087 04/03/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 Residents Affected - Some Findings include: On 3/31/25 at 2:00 PM, R3 was observed to have a brown substance embedded underneath R3's fingernails. On 3/29/25 at 9:05 AM, R4 stated that R4 is not receiving showers/complete bed baths. R4 stated that he does not recall the last time he was bathed. R4 stated that it takes up to an hour for staff to answer his call light. R4 stated that he has to wait his turn. R4 stated that there are others worse off than he is. R4 stated that he tries to do things for himself but it is not working too good. On 3/29/25 at 10:16 AM, R7 stated that R7 has not received a shower/bath since admission to this facility on 3/20/25. R7 stated that R7 washed himself in the bathroom today as best he could. On 3/29/25 at 3:00 PM, R1 stated that R1 has not received a complete bed bath since returning from hospital on 3/15/25. R1 stated that this facility does not have any barrier cream, the staff informed R1's family member that he would need to speak with the wound care nurse to get some barrier cream. R1 stated they are always shorthanded here, the Certified Nursing Assistant/CNAs have more than 20 residents each. R1 stated that she activated her call light at 1:30 PM and at 2:30 PM she still was not changed. On 3/31/25 at 2:00 PM, R3 stated that R3 has not received a shower/bath since admission to this facility on 3/25/25. R3 stated that R3 is starting to smell. R3 stated that if he can smell himself, he knows others smell him too. R3's family member was present at bedside and stated that R3 was given a bedpan to have a bowel movement. R3 stated that he was unsure how long he was on the bedpan waiting to have it removed and get cleaned up before his family member came in. R3's family member stated that it took 35 minutes after she arrived to get staff to assist R3. On 3/29/25 at 11:05 AM, V2 DON (director of nursing) stated that residents receive showers/complete bed baths twice a week, one on day shift and one on evening shift. V2 stated that residents can receive shower/complete bed bath when requested. Resident shower sheets for February and March 2025 requested on 3/29/25 at 2:00 PM and again on 3/31/25 at 11:33 AM. Shower sheets were not made available to this surveyor to review during the survey. R1's MDS (minimum data set), dated 2/20/25, notes R1 is totally dependent on staff for bathing, toileting, and personal hygiene. R3's functional abilities assessment, dated 3/26/25, notes R3 requires substantial/maximum assistance with bathing and toileting. 145087 Page 3 of 6 145087 04/03/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0677 R4's MDS, dated [DATE], notes R4 requires substantial/maximum assistance with bathing and toileting. Level of Harm - Minimal harm or potential for actual harm R7's MDS, dated [DATE], notes R7 requires moderate assistance with bathing and toileting. Residents Affected - Some This facility's bathing policy, revised 3/17/25, notes all residents are offered a bath or shower at least one time per week. More frequent bathing or showering is given as needed or requested. 145087 Page 4 of 6 145087 04/03/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: On 3/29/25 at 8:45 AM, the assignment sheet notes no CNA was assigned to residents in rooms on the east and northeast unit. Thirteen residents reside in these rooms. On 3/29/25 at 9:30 AM, V5 CNA was observed being informed by V9 CNA that V5 needed to take an assignment because one CNA did not come to work today. V5 stated that V5 is supposed to be transporting residents to and from dialysis. On 3/29/25 at 10:00 AM, V17 (restorative aide) stated that V17 was just informed V17 needed to pick up an assignment. V17 was observed to start providing care to residents in rooms on the east and northeast unit. On 3/31/25 at 2:00 PM, R3 was observed to have a brown substance embedded underneath R3's fingernails. On 3/31/25 at 2:00 PM, R3 stated that R3 has not received a shower/bath since admission to this facility on 3/25/25. R3 stated that R3 is starting to smell. R3 stated that if he can smell himself, he knows others smell him too. R3's family member was present at bedside and stated that R3 was given a bedpan to have a bowel movement. R3 stated that he was unsure how long he was on the bedpan waiting to have it removed and get cleaned up before his family member came in. R3's family member stated that it took 35 minutes after she arrived to get staff to assist R3. R3's family member stated that she expressed a concern on 3/26 regarding call lights and the wait time for staff to come to R3's room. R3 and R3's family member stated that there has been no improvement in the care provided. R3's family member pointed to a large pile of dirty linens on a chair and stated this has been here since he was admitted to this facility. R3's functional abilities assessment, dated 3/26/25, notes R3 requires substantial/maximum assistance with bathing and toileting. R3's BIMS (brief interview of mental status) score was 12 out of 15. On 3/29/25 at 9:05 AM, R4 stated that R4 is not receiving showers/complete bed baths. R4 stated that he does not recall the last time he was bathed. R4 stated that it takes up to an hour for staff to answer his call light. R4 stated that he has to wait his turn. R4 stated that there are others worse off than he is. R4 stated that he tries to do things for himself but it is not working too good. R4's MDS, dated [DATE], notes R4 requires substantial/maximum assistance with bathing and toileting. R4's BIMS score is 11 out of 15. On 3/29/25 at 10:16 AM, R7 stated that R7 has not received a shower/bath since admission to this 145087 Page 5 of 6 145087 04/03/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0725 facility on 3/20/25. R7 stated that R7 washed himself in the bathroom today as best he could. Level of Harm - Minimal harm or potential for actual harm R7's MDS, dated [DATE], notes R7 requires moderate assistance with bathing and toileting. R7's BIMS score is 15 out of 15. Residents Affected - Some On 3/29/25 at 3:00 PM, R1 stated that R1 has not received a complete bed bath since returning from hospital on 3/15/25. R1 stated they are always shorthanded here, the CNAs have more than 20 residents each. R1 stated that she activated her call light at 1:30 PM and at 2:30 PM she still was not changed. R1's MDS (minimum data set), dated 2/20/25, notes R1 is totally dependent on staff for bathing, toileting, and personal hygiene. On 3/29/25 at 12:00 PM, V4 (staff scheduler) stated that staffing is based on the facility's census. V4 stated that they are budgeted for 28 CNAs (certified nurse aides) and 21 nurses per day for 140 residents. V4 stated that typically there are 11 CNAs on day shift, 11 on evening shift, and 7 on night shift. V4 stated that typically there are 6 nurses on day shift, 6 on evening shift, and 5 on night shift. V4 stated that the day shift for nurses and CNAs 6:30 AM. V4 offers no explanation why staff assignments changed three times between 6:30 AM and 10:00 AM or why no staff was assigned to one set of rooms on the east nursing unit until 9:30 AM. On 3/29/25 at 12:08 PM, V5 CNA stated that V5 was scheduled to work as dialysis transporter today. V5 stated that V5 works weekdays from 12:00 PM-8:00 PM and weekends from 9:00 AM-5:00 PM. On 3/29/25 at 12:15 PM, V6 CNA stated that V6 is working on the west nursing unit today. When questioned if V6 is able to meet the needs of assigned residents, V6 stated that it depends on the number of CNAs working that day. V6 stated that if there are only two CNAs working on the west nursing unit, then each CNA has 17 or more residents. V6 stated that V6 is not able to complete showers, respond to call lights, toilet/provide incontinence care, turn/reposition residents, and chart. V6 stated that there is no definite assignment until 9:00 AM routinely and they start at 630 AM. V6 stated that sometimes V6 is informed of assignment changes. V6 stated that yesterday one CNA called off so only had two CNAs on the west nursing unit. On 3/29/25 at 12:25 PM, V7 CNA stated that if a CNA calls off, assignment will change until another CNA comes in. V7 stated that yesterday nobody showed up for front set on the northeast nursing unit in the morning. V7 stated that V7 stayed in her area but helped the nurse passed breakfast trays to the front set residents until staff came in. On 3/29/25 at 12:50 PM, V8 CNA stated that V8 floats to all nursing units. V8 stated that for the past one month she has worked on west nursing unit. V8 stated that most of the time V8 is assigned to 17 residents. V8 stated that the assignments change routinely, sometimes V8 is not told. V8 stated that V8 does not start her assignment until she knows for sure she isn't going to be pulled to another unit. V8 stated that previously V8 would start her work and then get pulled to another area and is required to chart on both assignments. 145087 Page 6 of 6