Inspection·April 8, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure residents did not smoke/vape in the facility. This failure applied to one (R2) of one resident reviewed for supervision. Residents Affected - Few The findings include: On 4/8/23 at 8:05 AM, there was a strong smell of marijuana on the first floor upon exiting the elevator. At 1:25 PM, V6 Nurse showed this surveyor R2's vape pen stored in the medication cart. The pen was a nicotine pen and did not smell of marijuana. On 4/8/23 at 8:58 AM, V2 Director of Nursing (DON) stated we keep taking away a vape pen from a resident identified as R2. R2's nicotine vape pen smelled like marijuana, so we keep it in the nurse's cart. V2 was notified by this surveyor that the second floor smelled of marijuana at 8:05 AM today. V2 stated R2 probably has another vape pen. R3 and R7 smoke cigarettes and go outside to smoke. Smoking hours are 7-8 or 8-8. At 9:56 AM, R4 stated, It already started this morning. I smell marijuana on the first floor. R4 stated that R2 smokes in her room and sprays air freshener or opens her window. I know the smell of it. I was around it at home and used to smoke it to help with a chronic medical condition. At 10:13 AM, R5 stated there's a marijuana smell in the hall. It happens when there's no Administrator or anyone in the building. I think it comes through the air vent outside our room. R2 is doing it (mentioned her by name). She has shown it to me before. She smokes joints and smokes it out of a vape. I know the smell of pot. My son smokes it. She does not go out at smoking times. It's highly dangerous. We have oxygen on this floor, and she smokes it in her room. I told the Administrator about the concerns of marijuana smoking in the building. She said she'll look into it. Some other residents are afraid to say anything about the pot smoking bothering them. They're afraid of her (R2). At 10:21 AM, R6 stated I have trouble breathing. I use that machine at night. Just talking to R2 you can smell it (marijuana) on her breath. I can smell it in the hallway. It's offensive. It aggravates my breathing. She smokes it almost every day. V1 Administrator and V2 DON talked to her about it. R2 is the only pot smoker here. She does not go outside to smoke her pot. She should go outside to do it. At 10:36 AM, R3 stated there's only two people who go out to smoke here, me and another guy (R7). (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 2 Event ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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)