Inspection·May 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the fall prevention interventions for cognitively impaired residents who are also at risk for falls. This failure has the potential to affect 5 residents, R3, R4, R5, R6, and R7 out of 7 reviewed for proper footwear as a fall prevention intervention. Findings include: On 5/27/25 at 11:20am during observation of residents in the second-floor dining room, the following were observed: R3 was observed sitting in the wheelchair in the day room with white socks that are smooth on the bottom. R4 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R5 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R6 was observed sitting in the wheelchair in the day room with other residents with dark grey socks that are smooth on the bottom. R7 was observed sitting in the wheelchair in the day room with other residents with black socks that are smooth on the bottom. Again on 5/27/25 at 11:45 AM, all 5 residents still had the same socks on. At this time, V6(CNA/Certified Nurse Assistant) was notified. V6 stated We will get the non-skid socks for them. The non-skid socks are needed to prevent falling. On 5/27/25 at 12:10pm, V7(Restorative Nurse) stated All residents need to wear nonskid socks so keep them from falling. I will make sure. Please, can you give me the names of the residents? On 5/27/25 at 12:15pm, V8 (Unit Manager) stated I am the unit manager; they told me that some residents don't have the nonskid socks. We have some in the storage and we will make sure that the residents wear the socks. (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 3 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 05/29/2025 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)