Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to follow its policy on conducting background
checks for one (V11) of 10 employees reviewed for background checks. This failure has the potential to
affect 61 residents currently residing in the facility.
Residents Affected - Many
Findings include:
Per census report, there are 61 residents currently residing in the facility.
On 07/16/24 at 2:00pm V3 (Human Resources) completed background screening check for 10 employees.
V3 stated, I cannot find the background check reports for V11 (Certified Nursing Assistant). V11 has been
working here since 03/18/2024. V11 is missing the Illinois Sex offender and Department of Correction
(DOC) sex Offender, DOC Inmate search, DOC wanted fugitive report, National Sex Offender report and
Office of Inspector General (OIG) report.
On 07/16/2024 at approximately 3:00 pm surveyor was provided with Illinois Sex offender and Department
of Correction (DOC) sex Offender, DOC Inmate search, DOC wanted fugitive report, National Sex Offender
report and Office of Inspector General (OIG) reports with search dates of 07/16/2024.
On 07/17/24 at 10:15 AM V3 stated, I think I (V3) forgot to run V11's background checks. I do not have any
other explanation. I am not sure how I let that slide by. I (V3) ran the background checks yesterday and
provided them to you.
On 07/17/24 at 10:19 AM Administrator (V1) stated, my expectation regarding background checks is that
they are all completed prior to start date.
On 07/17/24 at 3:41 PM V5 (Former Administrator/Administrator trainer) and (V1) Administrator stated, we
do not have a background check policy. We go off the regulations. When asked what regulations they were
unsure and said that they would have to check and get back to us.
On 07/18/2024 at 8:23 AM (V1) provided the following link:
https://www.dhs.state.il.us/page.aspx?item=48125 as what they follow for background check guidelines.
This link contains PROFESSIONS, OCCUPATIONS, AND BUSINESS OPERATIONS (225 ILCS 46/) Health
Care Worker Background Check Act.
Which states in part: (d) On October 1, 2007 or as soon thereafter as is reasonably practical, in the
discretion of the Director of Public Health, and thereafter, a health care employer who makes a conditional
offer of employment to an applicant for a position as an employee shall initiate a fingerprint-based criminal
history record check, requested by the Department of Public Health, on the applicant, if such a background
check has not been previously conducted. Initiate means obtaining from a
(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 4
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
07/18/2024
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)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
student, applicant, or employee his or her social security number, demographics, a disclosure statement,
and an authorization for the Department of Public Health or its designee to request a fingerprint-based
criminal history records check; transmitting this information electronically to the Department of Public
Health; conducting Internet searches on certain web sites, including without limitation the Illinois Sex
Offender Registry, the Department of Corrections' Sex Offender Search Engine, the Department of
Corrections' Inmate Search Engine, the Department of Corrections Wanted Fugitives Search Engine, the
National Sex Offender Public Registry, and the List of Excluded Individuals and Entities database on the
website of the Health and Human Services Office of Inspector General to determine if the applicant has
been adjudicated a sex offender, has been a prison inmate, or has committed Medicare or Medicaid fraud,
or conducting similar searches as defined by rule; and having the student, applicant, or employee's
fingerprints collected and transmitted electronically to the Illinois State Police. Health Care Worker Registry
(HCWR) Clearance This clearance must be conducted at the time of hire and annually thereafter to confirm
whether new hires or other employees have a criminal background check result reported to the HCWR. It
will also confirm whether the person has a disqualifying criminal conviction, if criminal background check
results are not reported on the HCWR for employees, they must immediately obtain a fingerprint criminal
background check result using a livescan vendor approved by state agency.
Event ID:
Facility ID:
145658
If continuation sheet
Page 2 of 4
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
07/18/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review the facility failed to: 1) follow their policy and procedures
for ensuring food is prepared and served under sanitary conditions by not using PPE (personal protective
equipment) properly when serving food, 2) Ensure food items were labeled and dated per facility policy, 3)
Ensure no expired foods, and 4) Ensure Staff wear hair restraint in kitchen area. This applies to 61
residents that receive oral nutrition and food prepared in the facility kitchen.
Findings include:
On 07/15/24 at 10:30 AM surveyor observed two bags of two-pound toasted oats cereal with expiration
date 6/21/23.
On 07/15/24 10:40 AM surveyor observed seven loaves of sliced wheat bread dated 7/10/24 in the storage
with two loaves of wheat bread molded and soggy, and one loaf of sliced wheat bread molded on the table
by the kitchen.
On 07/15/23 at 11:00 AM surveyor observed two opened half bags of shred lettuce dated 7/10/24 brown
and wilted in the refrigerated. V12 (Dietary Manager) stated, 7/10/24 is the received dates, there is no sold,
consumed, or discarded dated on the bread or lettuce.
On 07/15/24 at 10:45 V19 (Cook) said, expired food needs to be removed and discarded, I did not see the
mold on the bread. V12 stated, it is expected that staff will check the date and remove expired food.
On 07/15/24 at 12:00PM surveyor observed V12 serving food from the tray line without wearing gloves
touching trays, utensils and clean plates and adjusting eye faces on her face.
On 07/15/24 at 12:30 PM surveyor observed V12 helping place tickets on the trays, and receiving plates
and adding bread to trays without wearing gloves and fingers were inside the clean plate with food. V12
touched her eyeglasses and touched the inside of the plates.
On 07/16/24 at 11:30 PM surveyor observed V12 using hair restraints on the top of the head and hair
exposed below her shoulders serving lunch to residents.
On 07/16/24 at 12:05 PM surveyor observed V12 serving food on the tray line and removed her gloves and
donned clean gloves on without hand hygiene. V12 moved to ticket section and receiving plate with food not
wearing gloves and placing tickets on the tray and getting bread to place on the plates. V12 touched
eyeglasses and plates without providing hand hygiene during.
On 07/16/24 02:00 PM V12 stated, I expect staff to wear hair restraints with all the hair inside, proper hand
hygiene when changing gloves and wear glove when handling food. V12 said, I did not realize I touched my
eyeglasses during food preparation and when I was getting the tickets. Hand hygiene needs to be done
when gloves were removed. I expect the food to be dated and the cook to check dates prior to using any
food and dispose any food that is expired. Food must be dated when they get to the facility and disposed
when it is expired.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145658
If continuation sheet
Page 3 of 4
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
07/18/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
On 07/17/24 at 01:00PM V20 (Infection Preventionist) stated, I expect staff to perform hand Hygiene before
donning gloves and after removal of gloves and when hands are contaminated. Kitchen staff are expected
to wear hair restraints in the kitchen. Hair is expected to be inside of the hair restraints.
On 07/17/24 at 02:00 PM V2 (Director of Nursing) stated, I expect staff to do hand hygiene before donning
gloves and after removing gloves, staff must wear hairnets when they are working in the kitchen, and food
must be dated and expired food disposed.
On 07/17/24 at 02:09 PM V5 (Former Administrator trainer) stated, I expect staff to wear hair restraints in
the kitchen and, all food to be labeled with expiration dates and expired food to be discarded.
Facility Policy Titled Labeling and Dating Foods (Date Marking) dated 2020. Which reads in part (but not
limited to),
2- Date marking for refrigerated storage food items Unopened cases of refrigerated food items will be dated
with the date the item was received into the facility and will be stored using the first in - first out method of
rotation. Once a case is opened, the individual, refrigerated food items are dated with the date the item was
received into the facility and placed in/on the proper storage location utilizing the first in - first out method of
rotation. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date
according to current safe food storage guidelines or by the manufacturer's expiration date.
Facility Policy Titled Food Storage (Dry, Refrigerated, and Frozen) dated 2020. Which reads in part (but not
limited to),
a. All food items will be labeled. The label must include the name of the food and the date by which it should
be sold, consumed, or discarded. b. Rotate products so the oldest are used first. Staff shall be instructed to
use products with the earliest expiration date before those with a later expiration date. c. Discard food that
has passed the expiration date, and discard food that has been prepared in the facility after seven days of
storing under proper refrigeration.
Facility Policy Titled Proper Hand Washing and Glove Use dated 2020. Which reads in part (but not limited
to),
4- Employees will wash hands before and after handling foods, after touching any part of the uniform, face,
or hair, and before and after working with an individual resident. 5. Gloves are to be used whenever direct
food contact is required.
6. Hands are washed before donning gloves and after removing gloves.
Facility Policy Hair Restraints Dated 2020. Which reads in part (but not limited to),
Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas,
or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and
serving areas.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145658
If continuation sheet
Page 4 of 4
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations 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.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the July 18, 2024 survey of ALIYA OF PALATINE?
This was a inspection survey of ALIYA OF PALATINE on July 18, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALIYA OF PALATINE on July 18, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish staff and initial training requirements."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.