Aliya of Palos Park: Fracture Unreported for Hours - IL
Four hours passed.
The resident, identified in inspection records as R3, was described as confused at baseline. She weighed 98 pounds. She was in hospice. Her physician later told inspectors she had fragile bones and virtually no body padding, conditions that made her far more vulnerable to fractures than a typical patient. None of that moved the CNA, identified as V12, to report what had happened during that 3:30 a.m. interaction.
When morning rounds began, a nurse noticed discoloration on the left side of R3's head and on her left shoulder. R3 said she wasn't sure what had happened. She denied pain. She was sent to the hospital.
She came back that evening with a diagnosis of clavicle fracture and scalp bruise.
The facility's October 28 incident report documented the timeline plainly: the incident happened around 3:30 a.m., and the nurse on duty was not made aware until around 7:30 a.m. The nursing note from later that evening recorded R3's return from the hospital and noted her vitals were within baseline, with no signs or symptoms of pain or distress.
V12 told a supervisor, identified as V2, that R3 had bumped herself on the dresser. V12 said she checked and saw no bruising. She said she didn't inform the nurse because, in her assessment, nothing had happened and R3 had no marks.
V2 told inspectors she had already instructed V12 that anything happening with a resident needed to go to the nurse immediately. After the incident, V12 was suspended pending investigation.
R3's physician, V16, spoke with inspectors on the day of the inspection. He said the facility did make him aware of the incident, and he ordered R3 sent out even though she was in hospice, because she had hit her head. He was candid about the complexity of what happened.
"Not sure how the incident could have been avoided as the resident jerked during care," V16 said, explaining that R3 had moved suddenly while V12 was providing assistance. He said he wasn't in the room and was relying on what the CNA reported. "We want to say all fractures are avoidable but that is not always the case."
V16 described R3's physical condition in terms that made the outcome easier to understand, if not easier to accept. He said his own bones were stronger than hers, and that the same impact would not have fractured him. Her osteoarthritis, her age, her size, her lack of body fat — all of it contributed. He noted that given her hospice status, the care team was not focused on osteoporosis management. "She has no padding on her body and will break her bones more easily," he said.
What V16 did not equivocate about was the reporting failure. "The CNA needed to report this incident to the nurse," he said.
The facility's own job description for certified nursing assistants, cited in the inspection record, listed the obligation plainly: observe and report any physical or emotional changes in residents, and report all hazardous conditions to the nurse immediately.
V12 made a judgment call at 3:30 in the morning. She looked at a frail hospice patient who had just hit furniture hard enough to fracture her clavicle, saw no visible bruising, and decided nothing had happened. She did not wake the nurse. She did not document the contact. She moved on.
Whether the fracture itself was preventable is a question V16 left open, and it is a fair one. A resident who jerks unexpectedly during care, with bones that can snap from ordinary force, presents a genuine clinical challenge. But the four-hour silence that followed is not ambiguous. R3 lay in her room with a broken collarbone and a bruised scalp while the night shift continued and no nurse knew to check on her.
She was confused at baseline. She said she didn't know what had happened to her. She was not in a position to ask for help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aliya of Palos Park from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALIYA OF PALOS PARK in PALOS PARK, IL was cited for violations during a health inspection on November 24, 2025.
The resident, identified in inspection records as R3, was described as confused at baseline.
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.