Aliya of Palos Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jan 30, 2024

  Based on interviews and records reviewed the facility failed to ensure one resident's airway (R4) with a tracheostomy was free of obstruction by not removing the inner cannula during Cardiopulmonary Resuscitation (CPR) attempts. This affected one of three (R4) residents reviewed for emergency management. This failure resulted in R4 remaining in respiratory distress and the facility was unable to locate a spare trach tube to provide emergency oxygen during a Code Blue. R4 was transported to the local emergency room and pronounced deceased on the same day. The Immediate Jeopardy began on [DATE] when R4 developed respiratory distress and staff were unable to locate inner trach tube to provide oxygen and clear R4's airway. V7 (Administrator) was notified on [DATE] at 10:54 AM. […]

• Actual harm, isolatedF689Sep 4, 2025

  Based on interview and record review, the facility failed to provide adequate supervision and implement effective care plan interventions for one resident (R2) who was reviewed for falls. This failure resulted in R2 experiencing a right hip fracture as a result of a fall.Findings include:R2 has multiple diagnoses including but not limited to the following: delirium, altered mental status, acute kidney failure, metabolic encephalopathy, dementia, insomnia, psychosis, cognitive communication deficit, difficulty walking, and lack of coordination.Fall Risk Evaluation dated 7/13/2025 shows R2 has a fall risk score of 22.0 indicating resident is at high risk for falls.It is to be noted that R2 was sent to the emergency room following a fall on 7/16/2025 and has not returned to the… […]

• Actual harm, isolatedF689Aug 21, 2025

  Based on interview and record review, the facility failed to follow their hospice policy and care plan for one (R2) out of three residents reviewed for mechanical lift for transfer from chair to bed. This failure resulted in R2 sustaining a laceration on her left leg that required R2 to be sent to the emergency room for suturing. The after-emergency room summary indicates that R2 was treated for laceration repair. The facility's final summary investigation indicates that R2 returned to the facility with 17 sutures. Findings include:On 8/19/2025 at 11:37 AM, V4(Hospice CNA) said that V4 was transferring R2 to the bed, and V4 bumped R2's leg on the bed. V4 said that was when V4 saw the blood and V4 ran to get the nurse. […]

• Actual harm, isolatedF684Jul 31, 2025

  Based on interviews and record review, the facility failed to conduct comprehensive assessment and implement wound care management for one (R1) of three residents reviewed for skin alteration. This deficiency resulted in R1's abrasion on the left great toe deteriorated to necrosis, gangrene, infection of left foot, and needs amputation. Findings include:R1 is an [AGE] year-old, male, admitted in the facility on 07/03/25 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Type 2 Diabetes Mellitus without Complications; Pain in Right Foot; Pain in Left Foot; and Multiple Subsegmental Thrombotic Pulmonary Emboli without Acute Cor Pulmonale. […]

• Actual harm, isolatedF684Apr 25, 2025

  Based on interview and record review, the facility failed to treat elevated blood sugars that were above the resident's baseline before it got to a critical level and the facility failed to put in any interventions for a resident experiencing vomiting and diarrhea to prevent dehydration. This affected two of three (R81, R84) reviewed for nursing quality of care. This failure resulted in R84 being sent to the hospital with a blood sugar level of 521 mg/dL and was diagnosed with uncontrolled diabetes and R81 being sent to the hospital to be treated for severe dehydration after being diagnosed with norovirus. […]