Health inspection·February 13, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to the resident right to privacy by staff not knocking on the door before entering a resident's room. This failure affected two (R1, R4) of four residents reviewed for privacy. Findings include: R1 is [AGE] year-old male admitted to the facility on [DATE] with medical diagnosis that includes and not limited to hypertension, sleep apnea, obesity, right hip osteoarthritis, abnormal, gait and mobility, chronic and congestive heart failure. R4 is [AGE] year-old male admitted to the facility on [DATE] with medical diagnosis that includes and not limited to blindness, hypertension, diabetes, right eye surgery, Left eye surgery, Vitrectomy bilaterally. On 2/10/2025 at 12:00PM R1 said, I have concerns with staff coming into my room without knocking on the door or telling who they are. On 2/10/2025 at 12:20PM R4 said, I am blind, and I would like the staff to knock on the door and wait to come in, and when they come in introduce themselves and say their names. Some people I know by their voices, but I don't know everyone in the facility. There is sign on the door and staff still don't knock on the door and wait until I let them in. I like to have my privacy. On 2/10/2025 at 1:13PM V16 (Housekeeping) was removing garbage from R1 and R4's room; it was observed that V16 did not knock on the door before going inside. R4's room has sign posted indicating that R4 prefers to have staff knock on the door before entering. V16 said, I know I am supposed to knock on the door but I did not do it. On record review of facility grievances form dated 11/11/2024, R1 and R4 both had expressed that staff are not knocking on the door and waiting for a response before coming in. On 2/10/2025 at 1:15PM V6 (Nursing Manager) said, I expect the staff to knock on the door and wait for the resident to respond before the staff go in. On 2/10/2025 at 3:15PM V2 (Regional Director of Operations) said, I expect staff to knock on the door and wait for the resident to respond before going in. (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: 146058 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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)