Aliya of Palos Park: Staffing Gap Led to Resident Fall - IL
The nurse had been watching the woman, identified in inspection records as Resident 2, since early that morning. R2 had been trying to stand up repeatedly. The nurse was moving back and forth between the nurses' station and the common area, redirecting her, getting her to sit back down. Then the nurse turned her back and walked toward the station. She heard something move. When she turned around, R2 was on the floor.
The two aides assigned to the unit that morning were in another room, both of them, helping a different resident get out of bed. That resident required two people to move safely. The nurse said she had been the only one available to watch the common area at that moment.
Her unit holds between 43 and 50 residents. She told inspectors that most of them have dementia and behavioral symptoms. She said many of them require two-person assistance for basic care. She described a unit where the math, on any given morning, does not work out.
"I do not feel as if this is adequate staffing to properly care for all these residents," she told inspectors. It is a notable thing to say about your own workplace in a federal inspection interview. She said it anyway.
R2 had a fall care plan. It was updated on July 11, 2025, five days before she fell. The plan called for her to be placed in the common area while awake so that staff could monitor her closely. That intervention assumed someone would be available to do the monitoring. On the morning of July 16, the nurse responsible for the common area had her back turned when R2 tried to walk.
The facility's own fall prevention policy, last reviewed in February 2025, states that residents at risk for falls will have risk identified and interventions implemented to minimize that risk. R2 had the identification. She had the intervention. What she did not have, at the moment she stood up and fell, was anyone watching her.
Inspectors cited the deficiency under F0689, which covers accident hazards and supervision. They rated it as causing actual harm to a small number of residents. That rating means inspectors determined R2 was hurt, not that she might have been.
The nurse's account is what makes this inspection record unusual. She did not describe a system that failed in some abstract or procedural way. She described standing at a nurses' station, walking back and forth, doing what one person could do, and then hearing a sound and turning around too late. She described a unit where two aides helping one resident out of bed left no one else available. She described knowing, before the fall happened, that R2 had these behaviors, that R2 had been trying to stand all morning, and still not being able to stop it.
She was doing rounds on R2, she told inspectors, because they knew about the behaviors. The fall care plan existed because staff had already identified her as someone who needed watching. None of that prevented what happened on the morning of July 16.
R2 fell on her right hip.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aliya of Palos Park from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 24, 2026 · Our methodology
ALIYA OF PALOS PARK in PALOS PARK, IL was cited for violations during a health inspection on September 4, 2025.
The nurse had been watching the woman, identified in inspection records as Resident 2, since early that morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.