Inspection·April 18, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dementia unit before it happened, she (V16) would have had the opportunity to express her concerns so the facility could understand her reasoning for why she preferred R1 to stay on the 1st floor. V16 stated they could have a discussion about it, but the facility made the move without even notifying her (V16) before they moved R1. On 04/15/25 at 3:20 PM, V13 (Social Service Coordinator) stated the resident's family/POA/guardian are notified when a resident will be transferred to a different room or unit and this notification is documented in the resident's EHR in a progress note section by a social service staff member. V13 stated the facility can let the family know about the transfer the day before and/or the day of but the family/POA must be notified prior to when the transfer occurs. V13 stated the only time they do not notify the family is if the resident is responsible for themselves, and/or they do not have a Power of Attorney or guardian. V13 stated it is important to notify the POA/guardian about the room change so the family/POA/guardian is aware of the change. V13 stated on 04/07/25 in the afternoon, R1's family member came in to visit R1 and by that time R1 had already been transferred to the 2nd floor. V13 stated R1's family member who was visiting then called V16 (R1's POA) and then V16 called V13. V13 stated V16 was upset that R1 was transferred to the 2nd floor but V13 stated she had educated them when R1 was initially admitted that the 1st floor was not for long-term placement so V13 felt the family knew this transfer was coming eventually even if they did not know the specific day/time it was going to happen. V13 stated notification of the transfer was not addressed prior to the change happening. On 04/16/25 at 10:00 AM, V14 (Social Service Director) stated we normally figure out the room/unit the resident will be transferred to and then we notify the POA/guardian/next of kin verbally by telephone before the transfer occurs and we also notify them in writing by giving them a form called Notification of Room Change form. V14 stated the Notification of Room Change form specifies the date the notification was given and the reason for the room change. V14 stated it is important that the facility notify the POA/guardian ahead of the move when a change is going to be made so that they are aware that their loved one is going to be moved. On 04/17/25 at 9:10 AM, V2 (Director of Nursing) stated a resident's POA/guardian or responsive party should be notified verbally prior to the transfer and written documentation can be provided later when the POA/guardian is in the building. V2 stated it is important that they are notified ahead of time so they know where their loved one will be located before they come to visit the resident, so they know where to find them. V2 stated this is a resident's right and they should be provided with an explanation of why the transfer will be happening. V2 stated notification should be documented somewhere in the EHR about the verbal notification to the resident's responsible party about the pending transfer. V2 stated all documentation should be done in the EHR, the facility does not keep paper records and therefore, if it is not in the EHR there is no proof that it was done. On 04/17/25 at 12:59 PM, V1 (Administrator) stated for any resident getting transferred to a different room the POA/guardian should be notified before the transfer/change happens. V1 stated that is part of resident rights. V1 stated the notification can be done verbally in which case the conversation should be documented in the progress note section to prove that it happened. V1 stated if it is not documented in the resident's EHR there is no proof that it happened. V1 stated it was an oversight that R1's POA was not called ahead of time and V13 should not be backdating information in the progress notes. V1 stated it is his expectation that she (V13) enters the information in EHR when it occurs. R1's Notification of Room/Roommate Change form dated 04/07/25, 12:44 is blank for the section on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 2 of 3 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notification for the name of the resident/resident's representative notified, date written notification provided and reason for change. Facility provided policy titled, Room Change/Transfer within Facility dated 01/2025 documents in part, to assure the resident and/or their representatives are appropriately notified of room transfers, when a resident is being moved to a new room at the request of the facility, the residents, family or resident representative shall receive an explanation in writing of why the move is required. Facility provided document titled, Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities documents in part, you have the right to be told in advance and in writing if your room is being changed and you have the right to receive notice, including the reason for the change before your room or roommate in the facility is changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 3 of 3