Aliya of Evanston

In the surveyor’s words

From the most serious findings on record at Aliya of Evanston, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 9, 2024

  Based on observation, interview, and record review facility failed to provide a hazard free environment by allowing resident to be exposed to a stationary floor block heater near resident's bed after a fall for 1 of 3 residents (R1) reviewed for accidents/hazards in the sample of three. As a result of this failure, R1 laid on the floor for an undetermined amount of time in contact with the heat source. R1 was emergently sent to the hospital, and treated for second-degree burns and pain management. This was identified as an immediate jeopardy. The immediate jeopardy began on 01/02/2024 when R1 fell and came in contact with a heat source as R1 was positioned between the bed and the radiator. The immediacy was removed on 01/09/2024. […]

• Actual harm, isolatedF690Feb 25, 2026

  Based on interview, and record review, the facility failed to provide appropriate treatment and services for an indwelling urinary catheter for one resident (R1), resulting in a 4-hour period without nursing assessment or intervention when the catheter was not draining urine, leading to bladder distention and a traumatic bleeding insertion site injury that required immediate hospitalization. Findings include: R1 is a [AGE] year-old resident with a Brief Interview for Mental Status (BIMS) score of 15/15, and medical diagnosis including but not limited to paraplegia, complete; encounter for fitting and adjustment of urinary device; cystitis, unspecified with hematuria; hydronephrosis with ureteropelvic junction obstruction; acute kidney failure, unspecified; and calculus of kidney with… […]

• Actual harm, isolatedF726Feb 25, 2026

  Based on interview, and record review, the facility failed to ensure nursing staff possessed and demonstrated the competencies necessary to timely recognize, assess, and respond to a resident's acute change in condition and urgent call for help. This resulted in actual harm (significant bleeding requiring emergency hospitalization) for one resident (R1) who experienced a traumatic complication from an indwelling catheter insertion. R1 is a [AGE] year-old resident with a Brief Interview for Mental Status (BIMS) score of 15/15, and medical diagnosis including but not limited to paraplegia, complete; encounter for fitting and adjustment of urinary device; cystitis, unspecified with hematuria; hydronephrosis with ureteropelvic junction obstruction; acute kidney failure, unspecified; and… […]

• Actual harm, isolatedF689Feb 23, 2023

  Based on observation, interviews and record reviews, the facility failed follow facility policies and failed to provide adequate supervision and monitoring of a resident with cognitive impairment and behavior of wandering for one (R1) of four residents reviewed for accidents and supervision. This deficiency resulted in R1wandering into R2's room, was found on the floor and sustained a comminuted displaced right femoral neck fracture. R1 underwent a surgical procedure called right hip hemiarthroplasty. […]

• No harm, potential for more than minimal, widespreadF761Jan 24, 2025

  Based on observation, interview and record review the facility failed to discard expired opened medications from 2nd floor medication room. This failure has the potential to affect all 51 residents residing in the facility. Findings include: On 1/21/24 at 10:00am during medication room inspection on the 2nd floor, surveyor observed an open house stock Tuberculin purified Protein Derivative (TB) (5TU/0.1ml) 5ml (milliliters) vial that was about 75-80% full in the medication fridge on the 2nd floor. The vial had an open date of 9/26/24. […]