Inspection·September 4, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to investigate an allegation of abuse. This applies to 2 of 5 residents (R1 & R4) reviewed for abuse in the sample of 5. Residents Affected - Few The findings include: On August 29, 2024 at 9:30 AM, R1 was sitting up in his wheelchair in his room. He stated, he had a different room mate (R4) that called him a N****R. He reported it to V5 Registered Nurse (RN) and called the local police department. The police department came to the facility. They moved R4 out of the room and to a different room. On August 29, 2024 at 10:27 AM, V1 Administrator stated, R1 called the police on R4 for calling him a N****R. The police didn't do anything about it and R4 denied ever calling him that. She did not do an abuse investigation because she moved the resident out of the room and didn't treat it as an abuse allegation. On August 29, 2024 at 10:47 AM, R4 was lying in bed watching television. He stated, he was upset that R1 had the television on at 2 AM. R4 called the police pulling the race card. R1's progress note by V5 RN dated August 22, 2024 shows, Resident approached writer complaining about his roommate. Resident stated that he had a disagreement with the resident. Writer asked resident the details of the incident, he claimed that his roommate saying words that he does not like. Resident stated that he feels uncomfortable sleeping with his roommate around. He stated that he will call the police. He stated that he reported it earlier to the administrator. The police came and mediated with the situation. The facility did not provide any abuse investigation or further information. R1's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R4's Minimum Data Set, dated [DATE] shows, he is cognitively intact. The facility's abuse policy and prevention program dated October 2022 shows, Abuse policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation (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 09/04/2024 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)