Aliya Of Oak Lawn

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents.

Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device. On [DATE REDACTED] at 2:40pm, facility presented policy titled ‘Left Ventricular Assist Device' dated 01/2025,

review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, when a resident is admitted with in LVAD it will be noted in the medical record. Nurse will enter orders for LVAD care and monitoring based on discharge instructions from hospital or from LVAD clinical directly. All prothrombin time/international normalized ratio PT/ INR results, changes in resident condition, and equipment concerns will be directed to the LVAD clinic to which the resident is assigned.

Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not present when request was made to review the LVAD policy, procedures, and or protocol on [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED].The Immediate Jeopardy that began on [DATE REDACTED] was removed on [DATE REDACTED] when the facility took the following actions to remove the immediacy:1.

Regional Director of Operations in-serviced the Administrator regarding the facility's Abuse/Neglect Policy and Procedure on [DATE REDACTED] including neglect. The Administrator is the abuse coordinator and is responsible for ensuring all residents including Resident R1 are free from neglect. The neglect on [DATE REDACTED] was not reported to the Illinois Department of Public Health and an investigation was not sent until [DATE REDACTED]. The nurse was the identified staff member that was the alleged perpetrator of neglect towards Resident R1. The nurse was immediately suspended pending investigation. The nurse was terminated from the facility after the investigation was completed due to her failure to provide a clear and accurate report regarding the incident during her shift on [DATE REDACTED]. The facility in-serviced the facility staff on the neglect/abuse policy and properly rounding and checking on residents at least every 2 hours starting on [DATE REDACTED] 2. The nurse did not check on or complete vitals on Resident R1 during her 11pm-7am shift on [DATE REDACTED]. The nurse failed to check the LVAD battery of Resident R1 during her shift on [DATE REDACTED]. The Director of Nursing and Nurse Managers conducted in-services starting [DATE REDACTED] regarding LVADs and properly checking for batteries and alarms. The nurse failed to ensure the LVAD was connected to the wall outlet to ensure proper levels of the battery. The Director of Nursing and Nurse Managers conducted LVAD training with licensed staff on [DATE REDACTED] through [DATE REDACTED] that included to ensure LVADs are connected to the wall outlet at night to ensure that battery [TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

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 0655 Level of Harm - Minimal harm or potential for actual harm

Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not presented when request was made to review the LVAD policy, procedures, and or protocol on 09/17/2025, 09/19/25 and 09/23/2025. During this survey the surveyor was not able to identify what the specific orders should be in-place for a resident with an LVAD.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

are no orders for checking/monitoring the alarms, system, or batteries. Review of Resident R2's comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on [DATE REDACTED] to include the LVAD, V12 stated she knew the surveyor was reviewing for LVAD's. V12 was asked, what's the specific goals and interventions for the patient with the LVAD, V12 said the floor nurse are supposed develop a plan of care for baseline care needs upon admission within 24 hours, and the MDS team will review the comprehensive plan of care after. V12 did not give a response of what the baseline care needs are for a resident with an LVAD. V12 said she should not edit a resident record after they have discharged from the facility. On [DATE REDACTED] at 11:44am V17 (ADON-Assistant Director of Nursing) said she was

the preceptor for LVAD training. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 omitted what orders should be in-place for a patient with an LVAD.Facility policy titled baseline care plan dated 1/2023 last revision date 01/2025 denotes in-part to provide the staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of residence admission into the facility. The baseline care plan will include at a minimum of the following necessary information to properly care for a resident elopement risk fall risk supervision needs behavior interventions activities of daily living needs initial goals based on admission orders physician orders dietary orders therapy services social services pass our recommendations if applicable. Person centered care means that the facility focuses on the resident as the center [TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

unresponsive.Resident R1's plan of care for Resident R1 what's admitted to the facility for a skilled stay requiring physician ordered medically necessary services, including direct therapy services, skilled nursing care management, and evaluation of the patient care plan observation and assessment of the patient's condition and or teaching and training activities related to the reason for stay or in preparation for transition to a lesser care environment. Resident R1 requires skill services related to primary diagnosis aftercare s/p (status post) LVAD.Facility policy/protocol/ procedures for LVAD Patient Emergency Assessment denotes in-part: call rapid response team or 911. LVAD functioning? Auscultate left lower chest, continuous humming sound equals pump is working. No initiate: ACLS (advance cardiac life support) protocol, controller will probably be alarming: device check: check VAD parameters, controller alarm lights/sounds, continuous tone: urgent. Check power source. Check all cables connections. Change controller if instructed by VAD team. Transport urgently to ER (emergency room).Facility Emergency Response, denotes in-part VAD hazard alarm, call VAD team immediately (number listed) If patient is unresponsive: is VAD running? (listen for hum and check VAD numbers) YES: Treat underlying cause (patient could be unresponsive for other reasons; respiratory, stroke, blood sugar) NO: 1st attempt to get pump running quickly if unable to quickly okay to administer CPR and/or defibrillate. DO NOT disconnect VAD. If patient is responsive: Step 1-Check the connection between

the system controller and the LVAD, (driveline), Step 2-Check the connection between the system controller and the batteries or between the system controller and power-based unit. Step 3-If the device still fails to operate and patient is stable, call VAD coordinator: (phone number listed). The Immediate Jeopardy that began on [DATE REDACTED] was removed on [DATE REDACTED] when the facility took the following actions to remove the immediacy. 1. Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Emergency Protocol and Procedure for a resident with an LVAD on [DATE REDACTED]. The Director of Nursing and Nurse Managers completed education with nurses on the facility's Emergency Protocol and Procedure for a resident with an LVAD. The Director of Nursing and Nurse Managers also completed the education provided by the manufacturer (via Teams) to the facility nurses. 2. The Director of Nursing was in-serviced on [DATE REDACTED] by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care. The Director of Nursing provided education on [DATE REDACTED] through [DATE REDACTED] to licensed and unlicensed nursing personnel on emergency response for LVAD system. The emergency response procedure will be placed in the resident care plan and at the bedside. 3. The Director of Nursing and/or Nurse Managers will provide education to current nursing department staff with competency exams when facility admits any specialty care resident specifically LVAD. This process will be included in the new hire onboarding/orientation process. The facility nurses will also receive training competencies at minimum quarterly and as needed for staff caring for residents with specialty care needs.4. The facility has revised its staffing protocols on [DATE REDACTED] to ensure that at least one staff member trained in LVAD management is always on duty, including during all shifts, weekends, and holidays when there is an LVAD in the facility. The schedule is now maintained to verify proper coverage and trained staff assigned are being routinely audited by DON/designee. 5. The Director of Nursing and/or designee has educated licensed nursing staff on [DATE REDACTED] on recognizing and appropriately responding to LVAD-related emergencies including prioritization of device functions assessment during a code situation. Mock code drills incorporating LVAD scenarios will be conducted monthly, with documentation and debriefing to reinforce staff knowledge and readiness. Date: [DATE REDACTED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

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)

Federal health inspectors cited ALIYA OF OAK LAWN in OAK LAWN, IL for a deficiency under regulatory tag F-F0838 during a complaint investigation conducted on 2025-10-08.

Category: Administration Deficiencies

The facility was found deficient in the following area: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of ALIYA OF OAK LAWN.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-09.