Inspection·November 29, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's responsible party when initiating physician's orders, failed to notify a resident's responsible party regarding room changes, failed to notify a resident's responsible party with positive COVID test results. These failures apply to 1 of 3 residents (R1) reviewed for notification of changes in the sample of 7. The findings include: R1's electronic face sheet printed on 11/29/23 showed R1 has diagnoses including but not limited to Alzheimer's disease, Dementia without behaviors, major depressive orders, and malignant neoplasm of prostate. On 11/29/23 at 10:15 AM, V14 (R1's wife) stated, There have been a lot of things that I have not been notified about recently. My husband's roommate calls me and tells me when he moves rooms or when the doctor has seen him. I don't get the notifications from the facility like I should and I am his legal representative and have the right to know what his condition is and what room he is in. I went to visit him recently and his bed was empty and I couldn't find him. Come to find out, he had moved rooms because his roommate had tested positive for COVID. R1's Nurse Practitioner progress notes dated 11/20/23 showed, Dexamethasone 10mg x7days, complete blood count, and comprehensive metabolic panel ordered. (R1's nursing progress notes showed no documentation that V14 was notified of new orders). R1's COVID-19 Rapid Testing Results assessment dated [DATE] showed, Test Result: Positive .Notification: Physician/Nurse Practitioner. (R1's assessment and progress notes showed no documentation that V14 was notified of R1 testing positive for COVID). The facility's room move report printed on 11/29/23 showed R1 has moved rooms 5 times in the month of November 2023. R1's notes in his electronic medical record showed V14 was notified of 2 of the 5 room moves. On 11/29/23 at 10:43 AM, V4 (Licensed Practical Nurse) stated, Whenever a resident tests positive for COVID, we immediately notify the resident's representative if the resident is not alert and oriented enough to relay that information to their family. If a resident has to move rooms then the social service department notifies them. Anytime a new order is received, the nurse must notify the resident's representative so they are updated on the resident's current plan of care. We document these conversations in the resident's progress notes anytime we contact family members. (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: 145936 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 145936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Highwood 50 Pleasant Avenue Highwood, IL 60040 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)