Health inspection·July 5, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few On 7-3-24 at 10:32 AM, V19 (Licensed Practical Nurse) said R2 is alert, oriented x1-2, and able to make simple needs known. V19 said R2 has occasional confusion and R2 has no safety awareness. V19 said R2 is a fall risk and believes she can do things independently but can't. V19 said R2 will try to stand up and walk, take herself to the bathroom, and gets up without telling any staff. V19 said R2 requires assistance due to fall risk and history of falls. V19 said she was ambulating around the nurses' station, V19 redirected, and R2 became aggressive. V19 said she just finished passing medications and noted R2 ambulating by herself. V19 said CNA cleaned and dressed resident prior to incident. V19 said R2 was unattended at that time. V19 said R2 requires 1:1 because she tries to do things by herself. V19 said she was passing medications and CNA did not mention R2 was placed in common area or CNA was leaving R2 unattended. R2's admission Evaluation dated 5-23-24 documents: 1h. 19 (A score of 10 or higher indicates a High Fall Risk). Fall Risk Evaluation dated 5-24-24 documents: Score: 26 (Scoring a 10 or higher makes resident high risk for falls). State Reportable dated 5-24-24 documents: Incident Description: Resident was observed ambulating the hall, when nurse on duty attempted to redirect to seating area, she became resistant/ combative, NOD then allowed resident to ambulate and followed close behind as to not agitate resident further. While walking behind her, (R2) stumbled, falling to the floor and NOD was not able to break her fall. Upon assessment, (R2) left leg appeared to be shortened. Resident sent to ER for eval and was admitted with L hip fx. NOD made MD aware, received orders to send resident to ER for eval. EMS called; ETA of 30-60 minutes was given. Responsible party notified and agreeable with plan of care. NOD called ER and was made aware that resident was being admitted with dx of left hip fx. Investigation is ongoing. State Reportable (Final) documents: Summary of Investigation: (R2) had been awake and trying to ambulate since 1 am, when she was placed in common area for monitoring. At 0540, (R2) was observed ambulating and the nurse attempted to redirect her to the seating area, but (R2) became resistant and combative, so nurse allowed her to walk, but followed close behind her to not to agitate her to walk but followed close behind her not to agitate her further. As the resident continued to ambulate, she stumbled, falling to the floor, and the nurse was not able to break her fall. Hospital Record dated 5-24-24 documents: admission Diagnosis: (not limited to:) Closed left hip fracture, Displaced fracture of left femoral neck. Inpatient Problem List: Displaced fracture of left femoral neck, Closed left hip fracture. Principal Problem: Closed left hip fracture. Left hip fracture traumatic on pathological secondary to osteoporosis. Chief Complaint: witnessed fall. History of Present Illness: (R2) is an 81 y.o. female history of dementia, essential hypertension, generalized anxiety disorder, presented to hospital due to weakness falls at the nursing home resulted in left hip fracture she was admitted for surgical intervention per Ortho on consult. Progress note dated 5-24-24 documents: Resident was noted ambulating the unit. This writer came upon resident and was attempting to assist her to a chair. Resident became resistant/combative. This writer allowed resident to walk while walking behind her. Resident stumbled and fell to the floor; this writer was unable to break her fall. Resident landed into the CNA cart and ended up on her left side on the floor. Resident immediately grabbed her left leg and shouted in pain. Left leg appears shortened. This writer reached out to daughter and made her aware of situation. Orders received to send to Hospital for eval. All parties aware. Fall Prevention and Management Policy dated 1-23 documents: General: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for fall, plan for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0689 preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 3 of 3