Health inspection·August 21, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their hospice policy and care plan for one (R2) out of three residents reviewed for mechanical lift for transfer from chair to bed. This failure resulted in R2 sustaining a laceration on her left leg that required R2 to be sent to the emergency room for suturing. The after-emergency room summary indicates that R2 was treated for laceration repair. The facility's final summary investigation indicates that R2 returned to the facility with 17 sutures. Findings include:On 8/19/2025 at 11:37 AM, V4(Hospice CNA) said that V4 was transferring R2 to the bed, and V4 bumped R2's leg on the bed. V4 said that was when V4 saw the blood and V4 ran to get the nurse. V4 said that V4 transferred the resident from the wheelchair to the bed by herself. V4 said that R1 is a mechanical lift transfer resident. V4 said that V4 just did not use the mechanical lift and that was a mistake on V4's part. On 8/20/2025 at 1:50 PM, V4 said that V4 has been working with R2 for about 2 months. V4 said that V4 has been working as a CNA for about 17 years. V4 said that V4 received training on how to use mechanical lift from the hospice agency V4 works for. V4 said that V4 was not oriented on the facility mechanical lift. V4 said that although V4 was aware that R2 needs mechanical lift with 2 persons assist transfer, V4 said that V4 never uses the mechanical lift when transferring R2 from the chair to the bed since V4 has been caring for R2. V4 said that when V4 starts her shift, R2 has already been transferred from bed to her chair. V4's response to why V4 did not ask for assistance for transferring R2 was that everyone is busy doing their own thing, and as long as you do your job, you have no problem. V4 said they never had a situation like this since V4 has been working as a CNA, and V4 said that V4 felt bad for what happened.On 8/19/2025 at 2:01PM, V5 (LPN) said that the incident happened at the end of shift and V5 was the oncoming nurse. V5 said that V6 was the day nurse who V4 notified of the incident. V5 said that the wound care was notified of the injury and was already assessing the resident's injury when V5 went to see R2. V5 said that wound care nurse did her assessment and V5 notified the doctor and obtained an order for R2 to be sent out to the emergency room.On 8/19/2025 at 2:11 PM, V6 (LPN) said that V6 was R2 daytime nurse, and the incident happened around change of shift. V6 said that V6 was called into R2's room by V4. V6 said that V4 informed V6 that there is a cut on R2's leg. V6 said that V6 cleansed the area and applied a temporary bandage until the wound care nurse came down. V6 said that V6 notified the hospice nurse, wound care nurse, and then endorsed to V5. V6 said that no signs of pain or distress was notified. V6 said that to the best of her knowledge, it was the first time that V4 transferred R2 without the mechanical lift.On 8/19/2025 at 2:37 PM, V7 (CNA) said that R2 was assigned to her for the PM shift and V7 took care of R2 when she returned from the hospital 8/5/2025. V7 said that V7 was in room [ROOM NUMBER] performing patient care for the 2 residents in room [ROOM NUMBER]. V7 said that V7 was rounding on other residents. V7 said that she did not witness what happened. V7 said that R2 is 2 persons assist for transfer with Mechanical lift. V7 said that every time V7 takes Page 1 of 3 146053 146053 08/21/2025 Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464

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 146053 Page 2 of 3 146053 08/21/2025 Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464

F 0689 Level of Harm - Actual harm Residents Affected - Few 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. 146053 Page 3 of 3