Health inspection·August 21, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few care of R2, she always uses the mechanical lift when transferring R2.On 8/20/2025 at 12:29 PM, said V2 (ADON) said that V2 has been the facility ADON since 4/2025. V2 said that is little bit familiar with what is in the facility hospice policy but not word to word. The surveyor read out #7. protocol on the hospice policy which states, that the written contract between the facility and the hospice company must include, an agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's care and nursing needs in coordination with the hospice representative, and ensure that level of care provided is appropriate based on the individual resident's needs. V2 said that V4 should have used the mechanical lift during R2's transfer. V2 said that V2 is not aware of V4 being the CNA that cares for R2. V2 said that normally, hospice aide request assistance from the facility aide. V2 said that V4 should have requested for assistance and used the mechanical lift to transfer R2.On 8/20/2025 at 12:48 PM, V8 (Hospice Nurse) said that V8 said that V8 has been the nurse for R2 since 4/2022. V8 said that V8 received a phone call from V4 (Hospice CNA). V8 said that V4 told V8 that V4 was transferring R2 from the chair to the bed using 1 person transfer. V8 said that V4 said that when V4 laid R2 in bed, V4 noticed blood on R2's leg. V8 said that V4 said that V4 does not know how it happened. V8 said V8 used company issued Microsoft team to video chat with V4 to see R2's wound. V8 said that the wound looks to V8 as a deep skin tear. V8 said that V4 informed V8 that V6 (R2's facility RN) and wound care nurse were notified already. V8 said that V8 spoke to V6 and instructed V6 to send R2 to the ER for sutures. V8 said that V8 notified V3 (R2's son) about R2's injury and V8 recommendation for R2 to be sent out to ER for sutures. V8 said that V3 told V8 to have the facility call V3 when R2 is sent to the ER. V8 said that V8 called the facility and spoke to V5 (R2's PM shift RN) to call V3 when R2 is sent to the ER. V8 said that R2 is a mechanical lift with 2 persons assist transfer. V8 said that V4 has been working with R2 for about two months. V8 said that V4 should have used the mechanical lift when transferring R2. On 8/20/2025 at 1:59 PM, V1 (Administrator) said that V1 was on vacation when the incident happened. V1 said that what V1 knows, is what was reported. V1 said that R2 is a mechanical lift with 2 persons assist for transfer. V1 said that the floor nurse is V4's direct supervisor. V1 said that but the floor nurse is not expected to be directly overseeing R4's work. V1 said that the facility expectation is for the hospice company to send an aide with competent skills. V1 said that V4 (Hospice Aide) should have used the mechanical lift when transferring R2.Physician progress note dated 8/6/2025 at 12:36 PM stated, patient was being transferred without the use of a Hoyer lift and in the process of the transfer she sustained a laceration to her left calf. A photo of this wound was sent to me which appeared to be quite deep and long and therefore I advised staff to send her to emergency room for suturing.R2 is a [AGE] year-old lady admitted into the facility on 6/30/2017 with a brief interview of mental status of 00/15. Review of R2's physician order summary indicates that R2 was admitted to [NAME] Hospice on 4/21/2022. Review of facility report to IDPH of patient incident that occurred in the facility on 8/5/2025 indicates that R2 sustained an injury to her left calf during a transfer which led R2 to be sent to ER for placement of sutures. The report also indicated that R2 returned to the facility with 17 sutures. Review of the ER after visit summary indicated that R2 was treated for laceration closures. Review of the hospice nurse aide care plan and facility care plan for R2 indicate that R2's transfer from bed/chair and chair/bed should be done with a mechanical lift with 2 persons assist. [NAME] HEALTH CARE GUDELINE HOSPICEMANUAL - NURSINGREVIEW DATE - 1/2025 GENERAL: To provide guidance on how hospice services will be administered within the facility. A written agreement with the hospice that is signed by an authorized representative of the hospice provider and an authorized representative of the LTC facility before hospice care is furnished to a resident.PURPOSE: Ensure that (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 08/21/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the hospice services meet the professional standards and principles that apply to individuals providing services in the facility, and to the timelines of the services.RESPONSIBLE PARTY: IDTThe written contract must include the following:PROTOCOL:#7. An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice environment, and ensure that the level of care provided is appropriate based on the individual resident's needs. Event ID: Facility ID: 146053 If continuation sheet Page 3 of 3