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Complaint Investigation

Aliya Of Oak Lawn

October 8, 2025 · Oak Lawn, IL · 6300 West 95th Street
Citations 5
CMS Rating 2/5
Beds 191
Provider ID 145087
Healthcare Facility
Aliya Of Oak Lawn
Oak Lawn, IL  ·  View full profile →
Inspection Summary

ALIYA OF OAK LAWN in OAK LAWN, IL — inspection on October 8, 2025.

Found 5 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.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

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] 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], [DATE] and [DATE].The Immediate Jeopardy that began on [DATE] was removed on [DATE] 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] including neglect.

The Administrator is the abuse coordinator and is responsible for ensuring all residents including R1 are free from neglect.

The neglect on [DATE] was not reported to the Illinois Department of Public Health and an investigation was not sent until [DATE].

The nurse was the identified staff member that was the alleged perpetrator of neglect towards 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].

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] 2.

The nurse did not check on or complete vitals on R1 during her 11pm-7am shift on [DATE].

The nurse failed to check the LVAD battery of R1 during her shift on [DATE].

The Director of Nursing and Nurse Managers conducted in-services starting [DATE] 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] through [DATE] that included to ensure LVADs are connected to the wall outlet at night to ensure that battery [TRUNCATED]

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/08/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

SUMMARY STATEMENT OF DEFICIENCIES

During this survey the surveyor was not able to identify what the specific orders should be in-place for a resident with an LVAD.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/08/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

SUMMARY STATEMENT OF DEFICIENCIES

Review of R2's comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on [DATE] 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] 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]

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/08/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

unresponsive.R1's plan of care for 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. 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] was removed on [DATE] 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].

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] by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care.

The Director of Nursing provided education on [DATE] through [DATE] 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] 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] 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]

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/08/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aliya of Oak Lawn

6300 West 95th Street Oak Lawn, IL 60453

SUMMARY STATEMENT OF DEFICIENCIES

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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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OAK LAWN, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALIYA OF OAK LAWN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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