Aliya Of Evanston
ALIYA OF EVANSTON in EVANSTON, IL — inspection on February 25, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
resident, advice to wait few minutes before insertion of catheter again, but resident called 911 to be
them. At 2:00 AM, POA notified via a phone call. DON notified via a text message.The facility's
progress notes the size, procedure, urine color, amount, consistency, odor and resident response, and if the output for the shift is less than 200cc, the nurse should check the catheter for any kinks or leaks. If this is not the problem the physician or nurse practitioner should be notified of the low output.
146058 02/25/2026
Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201
inserted, but not all the way in and in the wrong place, by V3, on 02/04/2025. V9 said there were no
02/05/2026 between 11:30 PM and 3:00 AM, which could have provided essential information of R1's
02/05/2026, she got a call from the nurse on duty, V4, saying R1 called 911, and we (along with V3) reinserted his catheter. V2 said the next day, she gave V3 a re-competency to make sure he knew how to insert a catheter. V2 said V4 was not available, so she did not re-competency her. V2 said she was not sure what caused R1's bleeding. V2 said V4 told her she told V3 she was not comfortable with male catheters; so, she asked him for help. V2 said R1's diagnosis from the hospital said urethral bleeding. V2 said V3 and V4 should have documented the event better than they did.On 02/24/2026 at 5:33 PM, V10 (Medical Director) said V3 and V4 should have documented R1's catheter care on 02/04/2026 and 02/05/2026 because, if you're going to be accused of something, it's a good idea to document.On 12/19/2026 at 11:30 AM, Surveyor reviewed video footage R1 shared on his cellphone and claimed he took the morning of 02/05/2026, as soon as V4 had deflated his catheter balloon and had stepped out to get V3.
The video, lasting about sixteen seconds, was recorded from the perspective of a person lying down on a bed, and displayed blood on the person's diaper and significant blood inside a catheter bag and tubing.On 02/24/2026 at 9:21 AM, Surveyor called V4 but there was no answer. A voicemail message was left, with no reply.R1's hospital progress notes by V11 (Attending Radiologist) on 02/05/2026 at 7:45 AM, contained the following remarks:1. CT scan results 02/05/2026: Patient (R1) presenting with traumatic indwelling catheter insertion at SNF, bleeding continuously in ED, with CT abdomen/pelvis with contrast showing indwelling catheter balloon inflated in the bulbar urethra with free air and extravasation consistent with active bleeding. A large amount of blood is also present in the urinary bladder which is distended.
The bladder also contains air, presumably related to indwelling catheter placement.2.
Hgb (Hemoglobin) dropped from 13.2 to 6.5.3.
Patient became hemodynamically unstable with hypotension and tachycardia consistent with hemorrhagic vs. less likely septic shock, initially not fluid responsive, temporarily required Levo and ICU admission.R1's entire nursing progress notes documenting R1's catheter care of 02/04/2026 and 02/05/2026 were as follows:1.
Progress Note, 02/05/2026 4:19 AM, V4: R1 sent out to hospital for indwelling catheter reinsertion.2.
Progress Note, 02/05/2026 11:12 AM, V12 (LPN): R1 sent to hospital via 911 by self.3.
Progress Note, 02/05/2026 7:29 PM, V13 (LPN): hospitalized .4.
Progress Note, 02/05/2026 7:30 PM, V12: Writer called hospital. R1 is admitted for Traumatic Urethral Bleeding.Reviewed R1's electronic medical health record, including progress notes. No documentation of R1 having ever removed his own indwelling urinary catheter was found.R1's care plan, dated 12/18/2025, included the following interventions: Catheter monitoring and care as ordered; monitor and document intake and output as per facility policy; monitor for signs/symptoms of discomfort on urination and frequency; monitor/document for pain/discomfort due to catheter; and 10/08/2025 R1 was transferred to hospital due to hematuria on urine; returned to facility with stent placement.Reviewed R1's active medication orders, noting one anticoagulant medication, Enoxaparin Sodium, which R1 was prescribed to prevent blood clots.Reviewed a progress note from 10/08/2025 by V14 (Nurse): R1's indwelling catheter was changed, no urine drainage into bag, blood observed draining, catheter was removed, bleeding stopped, peri care complemented for resident, advice to wait few minutes before insertion of catheter again, but resident called 911 to be sent out. At 1:53 AM, medics arrived (5), transported resident to hospital, face sheet taken along with them. At 2:00 AM, POA notified via a phone call. DON notified via a text message.The facility's Catheterization of the Urinary Bladder Guideline, last reviewed 05/01/2025, states in part, chart in the progress notes the size, procedure, urine color, amount, consistency, odor and resident response, and if the output for the shift is less than 200cc, the nurse should check the catheter for any kinks or leaks. If this is not the problem the physician or nurse practitioner should be notified of the low output.