Health inspection·November 21, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include: Hospital paperwork service date 10/1/25 documents: Impressions/Recommendation-planning daily hemodialysis times three with incrementing time- third hemodialysis today three hours then will keep on Monday, Wednesday and Friday for now. R159 was admitted to the facility on [DATE] with the diagnosis of heart failure, chronic kidney disease stage four (CKD4) and diabetes. admission evaluation dated 10/10/25 documents: renal insufficiency, renal failure and end stage renal disease. Does resident receive dialysis: Yes. Type of dialysis: Hemodialysis. Dialysis access type and location of access site: Right subclavian port double lumen. Physician order dated 10/10/25 documents: Resident will receive dialysis IN-HOUSE on Monday, Wednesday, Friday. R159 care plan initiate on 10/22/25 documents: R159 needs dialysis (hemodialysis) related to CKD4. On 11/20/25 at 10:30am, V10 (dialysis nurse) said, he was not aware of R159 admission on [DATE]. V10 said, R159 was in the facility for six days without dialysis. V10 said, he had email corresponding that read R159 was going to be admitted to the facility. V10 said, he was never informed by medical record or any facility staff prior to 10/16/25 that R159 was admitted . V10 said, he was not given electronic access to R159 medical record. V10 said, dialysis does not have a way of knowing if a pending dialysis resident has been admitted to the facility unless dialysis is verbally informed or given electronic access to the resident chart by the facility. V10 said, dialysis is only granted access to dialysis residents by the facility. V10 said, dialysis cannot go in the facility electronic record to search for a resident. V10 said, he just happened to be in the hallway, taking another dialysis resident back to their room when V18 (nurse) asked him, when R159 was going to be dialyzed. V10 said, he replied, when was R159 admitted . V10 said, he returned to the dialysis unit, checked the computer and did not have access to R159's chart. V10 said, he went to R159's room, asked R159 if she receives dialysis, to which R159 replied, no. V10 said, he asked R159 if he could check for a dialysis catheter. V10 said, he unzipped R159 sweater and saw R159's dialysis catheter without a dressing located on her right chest wall. V10 said, R159 missed two scheduled days of dialysis due to the facility not notifying the dialysis unit that R159 arrived at the facility. V10 said, R159 was dialyzed without him having access to R159's electronic record. V10 said, V11 was called, updated about R159 missing two schedule treatments. V10 said, V11 ordered, R159 to run on low after having missed two treatments. V10 said, running low dialysis is done in order not to shift fluid to much fluid of the resident too fast. V10 said, due to R159 missing Residents Affected - Few Page 1 of 3 145087 145087 11/21/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0698 Level of Harm - Actual harm Residents Affected - Few two scheduled days of dialysis, R159 had to have dialysis two days in roll and her catheter was clogged. Facility email to dialysis dated 10/7/25 documents: R159 is clinically and financially approved for HD (hemodialysis). Facility email 10/10/25 at 11:36am documents: Hey patient is ready to admit today ETA (estimated time of arrive) pick up 7:00pm. Dialysis email to facility dated 10/10/25 at 12:51pm documents: Fantastic!! Please keep us posted on the patient's arrival so our unit know when to place her (R159) on the schedule. On 11/20/25 at 12:35pm, V2 (Director of Nursing/ DON) said, admission is primary responsible for notifying dialysis that a resident needs dialysis. On 11/20/25 at 12:44pm, V12 (admission) said, the admission nurse is given a notice that a resident with hemodialysis, had been admitted . V12 said, she is responsible for notifying the dialysis unit via email that a dialysis resident was admitted into the facility. On 11/20/25 at 1:04pm, V12 was asked who makes dialysis aware of a dialysis resident that is scheduled to arrive at 7::00pm. V12 said, she does not know who would make dialysis aware, she does not work at 7:00pm and she is not clinical. On 11/20/25 at 2:00pm, V11 (nephrologist) said, R159 was admitted to the facility but dialysis was not informed R159 was in the building. V11 said, the dialysis nurse is his contact to the facility. V11 said, dialysis is important to manage electrolytes. V11 said, dialysis treatments are done at a slow rate to prevent seizures and a quick drop in blood pressure related to complication associated with dialysis. On 11/20/25 at 2:17pm, R159 who was assessed to be alert and orient to person place and time, said she did not have dialysis when she first arrived to the facility. R159 said, a male staff member asked if had dialysis in the facility, to which she replied no, then that staff member asked if he could check for her dialysis catheter. R159 said, she was a new dialysis patient. R159 said, she did not know her dialysis days. R159 said, she was so confused when she was in the hospital. R159 said, the first day of dialysis was when a male staff member came into her room and asked to check her dialysis catheter. R159 said, she guess the facility realized that she had a dialysis catheter and took her to dialysis. R159 said, her legs were swollen with fluid filled blisters. R159 said, after dialysis her legs hurt so bad she cried all night. R159 said, she did not receive the care she needs. R159 said, she was treated poorly. On 11/20/25 at 4:30pm, V18 (nurse) said, when R159 returns from dialysis, she complained of pain to her legs from sitting in the dialysis chair so long. V18 said, R159 had weeping wounds on her legs. V18 said, R159 was provided pain management. Hemodialysis Treatment Flowsheet dated 10/16/25 documents: Patient arrived in wheelchair, alert and oriented times three, no apparent distress noted and denied complaints. CVC has no dressing intact, no sign or symptoms of infection or bleeding.Communication report dated 10/16/25 documents: Post treatment duration two hours and thirty minutes. Patient condition or events during/post dialysis: stable central venous catheter/CVC malfunctions required activase (used to dissolve blood clots in central venous access device (CVAD) for restoration of function to CVC. Hemodialysis Treatment Flowsheet dated 10/16/25 documents: Discharge to nursing home. Daily notes (general): patient tolerated treatment well but CVC malfunction prolonged HD session considerably. Hemodialysis Treatment Flowsheet Notes documents: Treatment initiated at 1616 (4:16pm); Treatment started without complications; during treatment at 1652 (4:52pm); Pt alert, no distress noted during treatment at 1723 (5:23pm);Pt alert, watching TV no complaints voiced at 1725 (5:25pm); Treatment pause for Cathflo administration during treatment at 1747 (5:47pm); Patient off treatment cathflo dwelling 1833 (6:33pm); Patient remains off treatment while Cathflo dwells during treatment at 1942 (7:42pm); Patient alert no complaints. Treatment resumed during treatment 2013 (8:13pm); Patient alert, denies complaint, access and lines visible during treatment 2044 (8:40pm); Alert patient watching TV no distress noted treatment ended 2101 (9:01pm); Treatment completed, blood returned post blood pressure sitting 2110 (9:10pm) On 11/21/25 at 2:57pm, V30 145087 Page 2 of 3 145087 11/21/2025 Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

F 0698 Level of Harm - Actual harm Residents Affected - Few (dialysis registered nurse) said, she was not notified of R159 admission until the 11/16/25. V30 said, she goes by her dialysis schedule for admission due to not having access to the resident's chart until the facility gives them access to the electronic record. R159 was a pending admission on their sheets Dialysis schedule dated 10/10/25 Friday, 10/13/25 Monday, 10/15/25 Wednesday documents: admit status: pending; patient: R159; date approved: 10/7/25; anticipated admission: [DATE]On 11/21/25 at 3:40pm, V2 (Director of Nursing/ DON) provide surveyor with a newly created Dialysis Acknowledgment Workflow which documents: admission Director will notify Dialysis Intake of any/new dialysis Admission. admission audit to be done by Unit Manager including Dialysis Orders. Unit Manager initiate and sign the Dialysis Acknowledgement Form. Once signed, Unit Manager hand the form to Dialysis Nurse to acknowledge and sign the form. Completed form will be submitted to the DON to verify and ensure that resident is added to the schedule. Dialysis Protocol dated 1/2023 documents: Dialysis in a facility. Receive home hemodialysis (HHD) or peritoneal dialysis (PD) treatment in nursing home, by trained and qualified staff who have received training and competency from dialysis facility. Shared communication between the facility and the dialysis facility. The care of the resident receiving dialysis service will reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. The communication process includes how the communication will occur, who is responsible for communicating and where the communication and responses will be document. 145087 Page 3 of 3