F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Based on record review and interview the facility failed to follow their abuse policy for two residents
(R1,R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately
intervening in a situation where residents became abusive to each other. Staff did not intervene in time
resulting in R1 and R2 engaging in a physical altercation that lead to them both putting scratches/abrasions
on each other's faces.
Finding Include:
R1's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face.
Classification abrasion. Doctor made aware , staff to continue to monitor.
R1s Nursing Note 4/25/2025 08:35 reads: was notified of the situation that occurred and will notify the rest
of her family. MD has also been notified.MD wants wound care to evaluate and treat. Resident does not
need to go out to the hospital at this time. Resident was separated and in stable condition. No
c/o(complaints of) pain or discomfort at this time. First aid applied.
R2's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face.
Classification abrasion. Doctor made aware , staff to continue to monitor.
R2'S Nursing Note4/25/2025 15:42 reads: MD wants wound care to evaluate and treat. Resident does not
need to go out to the hospital at this time. Resident was separated and in stable condition. No c/o pain or
discomfort noted. First aid applied.
On 5/6/25 at 10:45 am V3 (Certified Nurse Aide) stated she was sitting at the nurses station and saw R1
wandering down the hall and redirected her to sit down in the hallway by the nurses station. V3 stated R2
rolled to where R1 was sitting and heard them talking and heard R1 tell R2 to move her hand away. V3
stated as she was getting up from the nurses station when R1 stood up over R2 then they started wailing
their hands at each other. V3 stated she separated them both and the nurse (V6) came and assessed
them. V3 stated after they were separatedshe noticed scratches on both of their faces.
On 5/7/25 at 10:10 amV6 (Licensed Practical Nurse) stated she was getting off the elevator and saw R1
and R2 wailing their arms at each other while V3 was separating them. V6 stated they separated them and
took them to their rooms. V3 stated she noted after assessing R1 and R2 they both had small scratches on
their face. V3 stated she gave them first aide by cleaning the scratches with normal saline. V3 stated she
has worked on the Dementia unit for five years. V3 stated R1 had been on that unit for about a year and a
half, while R2 had lived up there for about three years. V3 stated she has
(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:
145983
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
05/09/2025
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 0600
never witnessed them getting into an altercation before like the one she had witnessed.
Level of Harm - Minimal harm
or potential for actual harm
V2 (Wound Nurse) stated on 5/6/25 at 11:15 am stated she was told by V6 to look at R1 and R2 faces
because they had gotten into a little scuffle. V2 stated noticed R1 had two small superficial
scratches/abrasions under her right eye and that R2 had a small scratches/abrasions on her top lip . V2
stated neither needed extensive treatment only they were cleaned and monitored for any signs of an
infection. V2 stated since the incident both resident scratches/abrasions have healed.
Residents Affected - Few
Facility's abuse policy reads the right of our residents to be free from abuse, neglect, exploitation,
misappropriation of property or mistreatment. The facility prohibits abuse, neglect, misappropriation of
property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal
punishment; and involuntary seclusion. Establishing an environment that promotes resident sensitivity,
resident security and prevention of mistreatment. Abuse is defined as the willful infliction of injury,
unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental
anguish.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145983
If continuation sheet
Page 2 of 2
