Inspection·January 6, 2026

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow the planned menu and failed to provide and document nutritionally equivalent substitutions when a menu item was unavailable. This failure affected one (R1) of four residents reviewed for dining. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to cirrhosis of the liver with ascites, hepatitis, hypertension, and hyponatremia. On the (MDS) Minimal Data Set assessment of 10/23/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 14/15, indicating the resident is cognitively intact. During interview with R1 on 1/5/2026 at 9:15 AM R1 said, last week they (facility) did not have milk for two days, last Thursday and Friday, and someone finally went across the street to the local supermarket and got milk but only got 2% milk. Finally, we got milk on Saturday we were very happy. During interview on 1/5/2026, at 9:35 AM, V3 (Certified Nursing Assistant) on the second floor reported that the facility did not have milk for two days last week (Thursday and Friday), day shift, and the facility was aware of this. During interview on 1/5/2026 at 9:51 AM, V4 (Certified Nursing Assistant) usually works on the 2nd floor, but I am floating to the first floor today. V4 said that last week, on dayshift on Thursday and Friday, the facility did not serve milk because they did not have it. During interview on 1/5/2026 at 2:20 PM, V5 (Certified Nursing Assistant) said, I worked last Thursday (01/012025) PM shift, we did not have milk to serve residents. I was assigned to serve the dining room, and we did not have milk. I don't know when the facility received the milk. I work on the second shift. During interview on 1/5/2026 at 2:25 PM, V6 (Registered Dietitian) said, Food service manager will order the food and supplies, but any menu changes need to be approved by the dietitian, and we use the log to make substitutions, and I usually sign for the substitution and make sure the changes are done properly. I was not aware of any milk shortage, and I did not make any substitutions. If I knew of the shortage, I would have ordered yogurt or cottage cheese to replace the milk so residents would get their proper calcium consumption. During interview on 1/5/2026 at 3:00 PM, V7 (Dietary Manager) said, I placed the milk order, and I did not work Tuesday and Wednesday (12/30/25 and 12/31/25), and I was expecting the delivery, but I did not know that the delivery never came, when I got to the facility on Thursday, 1/1/26, I called, but it was a holiday. The bill was not processed on time for the delivery, and that is why we did not get milk. The milk arrived on Friday afternoon. V7(Dietary manager) confirmed that on 1/1/2026 and 1/2/2026, the facility did not have milk, and someone had to go out to purchase milk for Friday 1//2/2026 until the facility received the delivery. When we don't have an item in the menu, we make substitutions, and we will add the changes to the food log substitution, and the dietitian will review and sign off on the changes. We usually change a protein to another protein, a vegetable to another vegetable, and poultry to another poultry. Milk can be substituted with yogurt and cottage cheese. Surveyors requested the policy for (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 01/06/2026 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)