Health inspection·February 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow physician orders to complete a comprehensive metabolic panel for one of three resident (R1) reviewed for physician orders. Residents Affected - Few Findings include: R1 face sheet shows R1 has diagnosis of Ogilvie syndrome, other specified myopathies, muscle wasting and atrophy, dysphagia, severe protein malnutrition, epilepsy syndrome, abdominal pain, cerebral palsy, hypertension, ileus, abdominal distension, constipation, severe intellectual disabilities, megacolon, mood disorder, ileostomy status, acquired absence of digestive tract, pressure ulcer stage 2 buttock, other seizures. R1 physician order sheet with order date of 10/15/24, start date of 10/21/24 denotes CBC W/DIFF (complete blood count and differentials) and platelets, comprehensive metabolic, magnesium, sent uncollected, one time only related to other seizures, Ogilvie's syndrome, cerebral palsy. Order dated 10/16/24 with start date of 10/21/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected, one time only related to one time only related to cerebral palsy, hypertension, other myopathies. Order dated 10/25/24 with start date 10/28/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected one time only related to other seizures, Ogilvie's syndrome, cerebral palsy, sent uncollected, one time only related to other mega colon. Order dated 10/30/24 with start date 10/31/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected one time only related to severe intellectual disabilities, mega colon, severe protein malnutrition. R1 physician progress note dated 10/29/24 denotes in part the patient needs to be assessed and monitored for DVT, change in mental status, infection, electrolytes imbalances, bowel and bladder issues, and pain issues. R1 current plan of care prior to transfer denotes R1 was admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation, and assessment of the patient's condition and/or teaching and training activities related to the reason for stay or in preparation to transition to a lesser care environment. R1 requires skilled services related to impaired mobility, weakness, assist with ADL's (activities of daily living) medication administration, lab monitoring, pain management, and wound care. R1 has an alteration in gastrointestinal status r/t (related to) previous medical history of Ogilvie syndrome, abdominal distention, and ileus. She is s/p (status post) colectomy with end ileostomy. Interventions are Monitor vital signs as ordered/per protocol and record. Notify MD (Medical Doctor) of significant abnormalities, (rapid pulse, shallow, rapid, or labored respirations, low blood pressure), obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. (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: 146053 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 02/10/2025 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)