Inspection·August 14, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure a resident took his medication at the time it was administered by leaving a medication cup at the bedside for 1 of 1 residents (R1) reviewed for medication administration in the sample of four. The findings include: The Face Sheet dated 8/13/24 for R1 showed diagnoses including delusional disorder, major depressive disorder, parkinsonism, cervical disc disorder, spinal stenosis, and history of falling. The Nurse's Note dated 8/9/24 at 8:29 PM, for R1 showed, At 5:00 PM, Writer entered residents room to administer due medications. Resident observed in the restroom and refused administration. At 6:00 PM, Writer entered residents room to re-attempt administration of medication. Resident refused. Reinforcement provided, resident continued to refuse. At 8:30 PM, Writer entered residents room with ADON (Assistant Director of Nursing) to assist with skin assessment, wound treatment and offer medication administration. Resident was observed in the restroom. ADON/Wound nurse offered skin assessment and wound treatment. Medications offered to resident by writer. Resident removed medication cup from writers hands and placed on bedside table. (R1) verbalized, Leave them there. I'm going to make a call. Resident refused to take medications in front of writer. ADON observed interaction. Writer exited the room due to the resident wanting to speak with ADON (Assistant Director of Nursing). The ADON later approached me and informed writer that the resident did not want writer to administer eye ointment medication. The MAR (Medication Administration Record) dated August 2024 for R1 showed on 8/9/24 at 5:00 PM his Propranolol HCL 60 mg and Senna plus 8.6-50 pills were signed out as given. On 8/13/24 at 2:11 PM, V3 (Assistant Director of Nursing/ADON) stated she went to R1's room with V4 (Licensed Practical Nurse/LPN) because she wanted to do a skin assessment. V3 stated they go in pairs when providing care for R1. The skin assessment was refused by R1 and V4 walked away. V4 brought R1 his medications. V3 stated she was outside of R1's door listening and R1 did not see her. R1 refused to have his vital signs taken. R1 did not want to take his medications in front of V4 and told V4 to leave his medications. V3 stated she went into R1's room and R1 stated he did not want V3 to give him his medications anymore. V3 stated she gave R1 his eye drops. V3 stated R1 had told V4 to leave his medications on the table. V3 stated it is not okay to leave the medications. V3 stated she personally would not leave the medications because she would not know if he took them or not. V3 stated V4 left R1 alone after that and did not go back into R1's room. V3 stated she did not check to see if R1 took his medications. V3 stated she did an assessment for R1 to be able to apply his petroleum jelly himself but an assessment was not done for him to administer his own medications. (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 08/14/2024 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)