Inspection·November 20, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications as ordered and follow the manufacturer's instructions for use. There were 25 opportunities with four errors resulting in a 16% (percent) error rate. This failure applied to two (R18 and R29) of four residents observed during medication administration.Findings include:R18 is an [AGE] year-old, female, admitted in the facility on 06/08/23 with diagnoses of Bilateral Primary Osteoarthritis, Other Asthma, and Essential Hypertension. R18's POS (Physician Order Sheet) documented:06/08/23: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg/dose (microgram per dose) (Fluticasone-salmeterol) 1 (one) inhalation inhale orally every 12 hours.12/03/23: Spironolactone tablet 50 mg (milligram) give 1 tablet by mouth one time a day.08/12/25: Voltaren Gel 1% (percent) (Diclofenac Sodium) apply to both knees and feet topically two times a day for pain 2 (two) gram dose. On 11/17/25 at 10:50 AM, V11 (Registered Nurse, RN) was observed passing medication on R18. It was observed that Advair Diskus was not administered. V11 stated he already administered it and showed surveyor the inhaler. The inhaler that was shown to surveyor was the Incruse Ellipta and not the Advair Diskus. In the MAR (medication administration record), V11 signed Advair as given but did not actually give during medication pass. Spironolactone was also not given because the medication was not available during medication pass. V11 stated Spironolactone was ordered last 09/25/25 and still waiting to be delivered to facility. At 11:43 AM, V11 is about to administer the Voltaren Gel on R18. V11 donned gloves, took the Voltaren Gel and squeezed an ample amount to gloved hand and rubbed the gel onto R18's right knee. Subsequently, he (V11) again squeezed a desirable amount to his gloved hand and rubbed it on her (R18) left knee. Voltraren Gel was not applied to R18's feet as ordered. Also, the amount applied on R18's knees did not indicate a 2 gram dose as ordered. R29 is a [AGE] year-old, male, admitted in the facility on 04/17/23 with diagnoses of Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery and Type 2 Diabetes Mellitus with Hyperglycemia.R29's POS dated 10/24/24 documented: Insulin Lispro Injection Solution 100unit/ml (unit per milliliter) inject 4 (four) units subcutaneously (SQ) with meals for hyperglycemia AND inject as per sliding scale: if 150-199 =2; 200-249 = 3; 250-299 = 4; 300-349 = 5. Call MD (Medical Doctor) if >350 mg/dl (milligram per deciliter), subcutaneously with meals for hyperglycemia. On 11/17/25 at 12:00 PM, V6 (RN) was observed administering Insulin Lispro 2 units on R29. V6 stated that only 2 units should be given to R29 because his blood sugar level was 167, and per sliding scale, only 2 units will be given. V6 was asked regarding the Insulin Lispro 4 units SQ with meals as standing order. V6 replied, I only give the 2 units, I just followed the sliding scale order, and not the other order of 4 units. The 4 units is just a reminder of the sliding scale order. They actually go together. Review of progress notes showed no documentation related to Insulin Lispro 4 units as to why it was not given. R29's care plan regarding diagnosis of Diabetes Mellitus insulin dependent recorded:Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. On 11/18/25 at 3:04 PM, V2 (RN/Interim Director of Nursing) was asked regarding administration of Voltaren Gel and insulin orders. V2 replied, For the Voltaren Gel, we have this card dose where we put the gel for the ordered dose. If it's for knees and feet, that will be two grams per application. For insulin orders, if there is a standing order for 4 units and sliding scale of let's say 2 units, the two units should be given along with the 4 units. Nurse should follow the orders. V2 was also asked regarding medications not given. V2 stated, When we give the medication, we sign. If the medication is not available at the time of administration, we document in the MAR that it was not given. Then we call the doctor and document any orders. Facility's policy titled Medication Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 2 of 4 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 11/20/2025 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administration dated 3/2025 stated in part but not limited to the following:General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline:1. An order is required for administration of all medication. 7. Read each order entirely. 13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. 14. Prepare or pour each dose of medication using an appropriate measuring device. 22. If medication is not given as ordered, document the reason on the MAR and notify the Health Care provider if required. Manufacturer's guidelines in dosage and administration of Voltaren Gel, dated July, 2009 documented in part but not limited to the following:2. Dosage and administration2.1 Dosing cardThe proper amount of Voltaren Gel should be measured using the dosing card supplied in the drug product carton. The dosing card is made of polypropylene, like the tube cap containing Voltaren Gel, but without the white colorant. The dosing card should be used for each application of drug product. The gel should be applied within the oblong area of the dosing card up to the 2 gram or 4 gram line (2 g for each elbow, wrist, or hand, and 4 g for each knee, ankle or foot). The dosing card containing Voltaren Gel can be used to apply the gel. The hands should then be used to gently rub the gel into the skin. After using the dosing card, hold with fingertips, rinse and dry. If treatment site is the hands, patients should wait at least one (1) hour to wash their hands. Patient Instructions for UseApplying Voltaren Gel to knees, ankles, and feet:2.To measure the right amount of Voltaren Gel, place the dosing card on a flat surface so that you can read the print. If the print is backwards, flip dosing card over.3.Squeeze Voltaren Gel onto the dosing card evenly up to the 4 gram line, making sure the gel covers the entire 4 gram area of the dosing card.4.Apply the Voltaren Gel to your foot, ankle or knee. You can use the dosing card to apply the gel. The hands should be used to gently rub the gel into the skin. Do not share the dosing card with another person.Make sure to cover your entire foot, ankle or knee area with the gel. For example, cover the skin above, below, inside and outside the knee cap. Remember that the foot includes the sole of your foot, the top of your foot and your toes. Event ID: Facility ID: 146058 If continuation sheet Page 3 of 4 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 11/20/2025 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure and offer pneumococcal vaccinations to new residents within seven days. This failure applied to four (R16, R25, R32, and R45) of six residents reviewed for vaccinations.Findings include:R16 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R16 has multiple diagnoses including but not limited to the following: cerebral infarction, type II DM, obesity, epilepsy, sleep apnea, and acute kidney failure.R25 is an [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R25 has multiple diagnoses including but not limited to the following: rhabdomyolysis, protein calorie malnutrition, HTN, cellulitis, CAD, and depression.R32 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R32 has multiple diagnoses including but not limited to the following: muscle disorder, gait and mobility abnormalities, lack of coordination, intracerebral hemorrhage, HTN, hemiplegia, dysphagia, and anxiety.R45 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R37 has multiple diagnoses including but not limited to the following: venous insufficiency, gait and mobility abnormalities, protein calorie malnutrition, acute respiratory failure, Type II DM, and COPD.R16, R25, R32, and R45's Immunization Report shows no pneumococcal vaccine was offered or given since admission.On 11/19/2025 at 1:32PM, V12 (Infection Preventionist) said we do not offer the pneumococcal vaccine to new admissions immediately upon entering our facility. Our process is to offer them at a scheduled clinic at a later date. I have been in this role for about six months and since then we have not had a vaccine clinic. We have our first vaccine clinic in about two weeks, and we will offer multiple vaccinations, including pneumococcal.Facility policy titled Pneumococcal Vaccinations with review date of 1/6/2025 states in part but not limited to the following: 1. All current residents or the resident's responsible party will be screened and offered the pneumonia vaccine within the first week of admission and annually, if eligible. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 4 of 4