Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aliya Of Palos Park during CMS and state inspections, most recent first.
A corporate wound care director tampered with an electronic monitoring camera in a resident’s room by turning it away from the resident during care. The resident had dementia and a BIMS score of 00, and the room had signage indicating live video monitoring. The resident’s sister reported this was the third time the camera had been moved, and the director acknowledged she did not know the law and had not checked with the nurse before moving the camera.
A resident with severe cognitive impairment, multiple comorbidities, a moderate Braden risk score, and an unstageable right heel pressure ulcer had physician and podiatry orders for foam heel boots to both feet and continuous offloading with no pressure to bony prominences. Surveyors observed the resident in a recliner and in bed with only one heel boot applied, while the other heel rested directly on the surface, and later observed wound care during which both heels were placed directly on the bed and ankles were allowed to rest against the opposite shin without offloading. The wound care nurse, senior wound care coordinator (LPN), DON, and CNA confirmed that boots should have been on both feet and that heels were not offloaded, and the CNA admitted only applying a boot to the wounded foot and being unaware of the orders. The care plan was not aligned with the physician orders for bilateral, continuous heel protection, and facility skin care policy requiring heel elevation and avoidance of skin-to-skin contact was not followed, despite family-posted signs in the room reminding staff to keep the boots on.
A resident with severe cognitive impairment, multiple comorbidities, an unstageable right heel pressure ulcer, and a history of right heel cellulitis on antibiotic therapy received wound care that did not follow clean technique or facility policy. During an observed dressing change, an LPN placed the resident’s heel on gauze after removing a soiled dressing with serosanguinous and purulent drainage, then dried the wound from the outside skin toward the wound bed instead of from the inside out. A regional wound care LPN intervened and identified that the technique used went from dirty to clean rather than clean to dirty, and the DON later confirmed that proper clean technique requires cleansing from the inside of the wound bed outward, as specified in the facility’s wound dressing policy.
A CNA failed to report to the nurse right away when a resident with dementia and hospice care jerked during incontinence care and struck her head and shoulder on a bedside dresser. The nurse was not informed until the next morning, when bruising was found and the resident was sent to the ER, where a clavicle fracture and scalp hematoma were diagnosed. Staff stated that any injury or change in condition was to be reported immediately to the nurse.
A resident with multiple high-risk conditions, including dementia and impaired mobility, was not adequately supervised despite being identified as a high fall risk. The resident was left unsupervised in the common area while the assigned LPN was at the nurse's station and CNAs were assisting another resident, resulting in a fall and right hip fracture. Staff interviews confirmed that close monitoring was expected but not provided, and the facility's fall prevention policy was not effectively implemented.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in increased risk for residents.
Two residents experienced significant changes in condition—one with vomiting, diarrhea, and low blood pressure, and another with rising blood glucose levels—without timely assessment, intervention, or physician notification by staff. In both cases, staff did not follow care plans or facility policies for monitoring and reporting, resulting in hospitalizations for severe dehydration and uncontrolled diabetes.
The facility did not serve pureed bread to residents on pureed diets as required by the posted menu, affecting several individuals. Staff confirmed that pureed bread was not prepared or provided due to the lack of bread puree mix, despite having recipes available.
Two residents and their families experienced long call light response times, with delays of 45 minutes or more reported multiple times per week, and their concerns were not formally documented or addressed by the DON. The facility also inconsistently enforced a new policy banning personal refrigerators in resident rooms, removing one resident's fridge while allowing another to keep theirs, without providing clear communication or education to all affected parties.
A resident was found calling out for help while seated in a Geri chair, with the call light placed out of reach on the bed. A CNA/Restorative Aide confirmed the call light was not accessible and subsequently moved it closer. The DON stated that staff are required to ensure call lights are within reach, as outlined in facility policy.
Two residents were placed in a semi-private room with video monitoring without proper informed consent from the residents or their POA, despite one resident having moderate cognitive impairment and a POA in place. Documentation of consent was inconsistent, and staff did not ensure that written consent was obtained and properly recorded in the EMR.
A resident with multiple risk factors for skin breakdown was not provided with a comprehensive care plan or thorough skin assessment upon readmission from the hospital. Staff failed to document the presence and treatment of wounds, and preventive interventions such as heel protectors were not consistently recorded. Facility policies requiring comprehensive assessment and person-centered care planning were not followed, resulting in inadequate documentation and uncertainty about the resident's skin care interventions.
Two residents with significant risk factors for skin breakdown did not receive comprehensive skin assessments or consistent documentation of preventive interventions upon admission or readmission. One resident with multiple comorbidities and a history of pressure ulcers was not properly assessed for wound status, and preventive measures such as heel protectors were not documented. Another resident with a stage 3 sacral pressure ulcer was placed on a low air loss mattress that was not set according to their actual weight, contrary to policy and manufacturer instructions. These deficiencies reflect failures in following facility protocols for pressure ulcer care and prevention.
A resident was observed with an indwelling catheter, but the physician order lacked documentation of the diagnosis or reason for its use. The DON confirmed that such documentation is required, and facility policy states that orders must specify the diagnosis or indication for the catheter, which was not done in this instance.
Two residents with significant weight loss and decreased oral intake did not have their meal consumption accurately documented, with observed intake not matching charted records and multiple meal opportunities lacking documentation. Despite ongoing nutritional interventions and weekly monitoring by the interdisciplinary team, incomplete and inaccurate documentation hindered effective tracking of their nutritional status.
The facility did not ensure that two residents received face-to-face visits from their attending physicians within the required timeframes, as documented visits were either delayed or missing, contrary to the facility's physician services policy.
A resident with macular degeneration was not assisted in obtaining transportation to a retinal specialist appointment after declining to pay a high out-of-pocket cost. Facility staff did not offer alternative transportation options or the in-house eye doctor, and there was no documentation of education or efforts to reschedule the appointment, despite care plan and physician orders indicating the need for ongoing ophthalmology consults.
Two residents did not receive their prescribed medications as ordered. One resident missed a scheduled dose of Midodrine due to unavailability, resulting in a significant delay in administration despite low blood pressure. Another resident did not receive a scheduled dose of steroid eye drops because the medication could not be given in the dining room, and the nurse chose to skip the dose. Both incidents were confirmed by documentation and staff interviews.
Expired ferrous sulfate tablets were found in a medication cart after their expiration date, and three bottles of oral liquid Lorazepam requiring refrigeration were improperly stored in a narcotic box. An LPN was unaware of the correct storage requirements, and a discontinued controlled medication remained in the cart instead of being disposed of as per policy.
Staff did not adhere to contact isolation protocols for a resident with an ESBL/VRE urinary tract infection, as required by facility policy and physician orders. On multiple occasions, staff entered the resident's room without the necessary PPE, including gowns and gloves, and there was confusion among staff regarding the resident's isolation status. The care plan also lacked documentation of the required contact isolation precautions.
A facility failed to complete a comprehensive metabolic panel (CMP) for a resident with complex medical conditions, despite multiple physician orders. The Director of Nursing was unaware of the missed lab draws until informed by the NP, and the facility could not present lab results for the specified dates. The issue was not with the contracted laboratory, indicating a failure in the facility's processes.
A resident with dementia and high fall risk fell and fractured her hip after being left unsupervised in a common area. Despite known impulsive behavior and poor safety awareness, the resident was unattended when a CNA left to perform rounds, and the nurse was busy with medication administration. The facility's fall prevention policy was not effectively implemented, leading to the incident.
The facility failed to supervise a high fall risk resident with Dementia, resulting in an unwitnessed fall and hip fracture. Another resident with Dementia fell from her wheelchair due to the absence of leg rests during transport, sustaining a forehead hematoma. Both incidents highlight non-compliance with the facility's fall prevention policy.
A resident with a history of falls and severe pain waited over 30 hours for a chest x-ray, which was delayed due to inadequate tracking and communication within the facility. The resident was eventually sent to the hospital and diagnosed with multiple rib fractures.
The facility failed to follow sanitizing guidelines by not sanitizing a knife and cutting board for the required 1 minute, as observed when a cook submerged them in sanitizer for only 1 second. This deficiency could affect 104 residents receiving an oral diet.
The facility failed to ensure mail was delivered to residents on Saturdays, affecting seven residents. During a resident council meeting, multiple residents stated that they do not receive mail on Saturdays and have to wait until Monday. An interview with the Life Enrichment/Activities staff revealed that Saturday's mail is placed in a locked administration office by the receptionist, and activity aides do not have access to this office. As a result, mail is only distributed to residents on Mondays.
The facility failed to follow their abuse policy by not immediately reporting a bruise of unknown origin on a resident to the immediate supervisor or the administrator. The bruise was noticed by staff members on different occasions prior to the official report, but it was not reported immediately as required by the facility's abuse policy.
The facility failed to notify a family member when a resident was sent to the hospital. The Director of Nursing confirmed that staff are expected to notify families of any change in condition, but a review of the resident's records showed no such notification was made.
A resident with aphasia had four hundred dollars stolen from his wallet due to the facility's failure to provide secure storage for personal items. The resident, who was alert but had communication challenges, reported seeing a staff member in his room but could not provide a complete description. Staff confirmed the resident had shown his money before it was stolen, and the facility did not offer secure storage options, suggesting families bring a lockbox instead.
Camera in Resident Room Was Tampered With
Penalty
Summary
The facility failed to respect a resident’s right to a dignified existence, self-determination, communication, and exercise of rights when a corporate wound care director tampered with an electronic monitoring camera in the resident’s room. The resident was [AGE] years old, not cognitively intact with a BIMS score of 00, and had diagnoses including dementia, Parkinson’s disease, major depressive disorder, chronic kidney disease, malnutrition, acute respiratory failure with hypoxia, and adult failure to thrive. The care plan documented that the resident’s POA preferred to have a camera in the resident’s room, and signage outside the room indicated that video surveillance was in use. During the incident, the corporate wound care director entered the room to provide care and turned the camera away from the resident to provide privacy for the resident and herself. The resident’s sister reported that this was the third time the camera had been moved and stated that it was a federal violation. The administrator later stated she had been informed that the camera had been moved and turned by the corporate employee, who believed she needed to give consent herself to be on camera and was not aware that obstructing a camera in a resident’s room was prohibited. The corporate wound care director stated she turned the camera slightly away from the resident, then turned it back after being told the sister was threatening to call IDPH, and acknowledged she had not checked with the nurse before moving it.
Failure to Follow Pressure Ulcer Orders and Offloading Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for pressure ulcer prevention and care for one resident with an existing right heel pressure ulcer and multiple comorbidities, including metabolic encephalopathy, dysphagia, protein-calorie malnutrition, dementia, Parkinson’s disease, and severe cognitive impairment (BIMS score 00). Hospital records and podiatry orders specified ongoing palliative wound care to the right heel, daily dressing changes, and offloading with heel protector boots at all times, with no pressure to bony prominences. Facility physician orders and medication review documented foam boots to both feet for pressure relief and daily dressing changes with silvadene cream and foot washing. The resident’s Braden score of 14 indicated moderate risk for pressure ulcers, and the wound summary documented an unstageable right heel pressure ulcer measuring 3.5 cm by 4 cm. On observation in the dining room, the resident was found sleeping in a wheeled recliner with a heel protector boot on the right foot only, while the left heel rested directly on the recliner surface without a boot. The restorative nurse confirmed the presence of a wound and that the resident should have had both boots on. Later, in the resident’s room, the wound care nurse and surveyor again observed that the left heel protector was not applied; the nurse retrieved a heel protector from the windowsill and applied it, acknowledging the resident was supposed to have both boots on and that staff had not put it on. The DON confirmed that staff should follow physician orders and that there were active orders for foam boots to both feet, acknowledging the left boot should have been on. The care plan, revised after these observations, listed an intervention to apply heel protector boots while in bed but did not reflect the physician orders for boots to both feet at all times or specify any resident or family preference limiting boot use. During a subsequent wound care observation, the wound care nurse and senior wound care coordinator removed both heel protectors and placed the resident’s heels directly on the bed surface during the dressing change, including placing a heel on a piece of gauze on the bed and leaving the heels non-offloaded throughout the procedure and skin check. When the resident was turned side to side, the ankles rested directly on the opposite shin, creating pressure between bony prominences. Both staff confirmed the heels were not offloaded and acknowledged that pillows or rolled blankets could have been used. A CNA who regularly cared for the resident reported applying only one boot to the foot with the wound and was unaware of the physician orders or care plan requiring boots to both feet. Handwritten signs from the resident’s family member in the room instructed staff to keep the green boots on the resident’s feet and to keep the right boot on even in bed, and the family member reported having to post reminders because the resident would not always be in the correct wheelchair or have boots on, expressing frustration with the care provided. Facility policy on skin care prevention required elevating heels off the bed surface and avoiding skin-to-skin contact, which was not followed during these observations.
Improper Wound Care Technique and Infection Control Lapses During Heel Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to perform wound care using appropriate infection prevention and control practices and to follow its own wound dressing policy for a resident with a right heel pressure ulcer and cellulitis. The resident had multiple diagnoses including metabolic encephalopathy, dysphagia, protein-calorie malnutrition, unspecified dementia, cognitive communication deficit, local skin infection, cellulitis of the right lower limb, Parkinson’s disease, and major depressive disorder, and had a BIMS score of 00 indicating severe cognitive impairment. The resident had been treated in the hospital for right heel cellulitis and was on antibiotic therapy for a right heel cellulitis and right foot infection, with an unstageable pressure ulcer to the right heel measuring 3.5 cm x 4 cm and a Braden score of 14 indicating moderate risk for pressure ulcer development. The podiatrist had ordered foam boots, daily dressing changes with gauze and silvadene cream, and daily foot washing followed by dressing. During an observed wound care procedure to the resident’s right foot, the wound care nurse (V3) removed a soiled dressing with serosanguinous and purulent drainage and placed a piece of gauze on the bed, then placed the resident’s heel directly on that gauze. After irrigating the wound with normal saline, V3 patted the wound dry in a circular motion from the outside skin toward the inside of the wound bed, contrary to clean technique. The senior wound care coordinator (V8) immediately objected, stating that wound care should be done from the inside of the wound bed to the outside skin and that care should always proceed from clean to dirty. V8 confirmed that V3 had gone from the outside skin to the inside wound bed, and V3 acknowledged not following clean technique and that this could introduce bacteria into the wound bed. The DON (V2) affirmed that proper clean technique requires cleansing from the inside out and that going from outside the wound to inside can introduce bacteria into the wound bed. The facility’s wound dressing policy requires wound dressing changes using clean technique with good hand hygiene and appropriate wound coverings, but the observed practice did not adhere to these standards.
Failure to Report Resident Injury Promptly
Penalty
Summary
The facility failed to report an incident to the nurse immediately when a CNA was providing incontinence care to a resident with dementia, hospice care, and multiple chronic conditions including hypertensive heart disease with heart failure, chronic pain syndrome, osteoarthritis, vitamin D deficiency, and a history of fracture. During repositioning, the resident jerked and struck her head and shoulder against a bedside dresser/nightstand. The CNA later stated she did not tell the nurse because she assumed the resident was okay and did not see bruising at the time. The resident was not assessed by the nurse until the following morning, when bruising to the left side of the head and left shoulder was observed during rounds. The incident report states the nurse on duty was not made aware until around 7:30 am, even though the incident occurred around 3:30 am. The resident was then sent to the ER, where she was found to have a comminuted fracture of the left clavicle, a frontal lobe scalp hematoma, and mild degenerative changes to the left shoulder. Staff interviews showed that CNAs and nurses expected any incident, injury, bruise, or change in condition to be reported to the nurse right away so the resident could be assessed and the physician notified. The night CNA acknowledged she failed to report the event immediately. The nurse on duty stated she was not informed of the incident before the bruising was discovered, and the DON confirmed the incident was not reported when it occurred.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement effective care plan interventions for a resident with multiple high-risk diagnoses, including delirium, dementia, and impaired mobility. The resident was identified as high risk for falls, with a fall risk score of 22.0, and had a recent history of falling. Despite care plan interventions requiring close monitoring in the common area, the resident was left unsupervised when the assigned LPN was charting at the nurse's station and two CNAs were occupied assisting another resident. During this lapse in supervision, the resident attempted to stand and walk, resulting in a fall and a right hip fracture. Staff interviews confirmed that the expectation was for high fall risk residents to be closely monitored in the common area, with staff in close proximity, not at the nurse's station. The LPN responsible for monitoring the resident was not present in the common area at the time of the fall, and staff acknowledged that the unit was understaffed to provide adequate supervision for the number of high-risk residents. The facility's fall prevention policy required identification and implementation of interventions for residents at risk for falls, but these were not effectively carried out, leading to the resident's injury.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. This lack of appropriate environmental safety measures and supervision directly contributed to the deficiency cited by surveyors.
Failure to Respond to Changes in Condition and Elevated Blood Glucose
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents. One resident with multiple comorbidities, including chronic kidney disease and congestive heart failure, experienced several episodes of vomiting and diarrhea, as well as low blood pressure and altered mental status. Despite these changes in condition, staff did not implement adequate interventions to prevent dehydration, such as monitoring intake or providing supportive hydration. The resident's family repeatedly expressed concerns and ultimately insisted on hospital transfer, where the resident was diagnosed with colitis and severe dehydration due to norovirus. Documentation and interviews revealed that staff were aware of the resident's symptoms but did not escalate care or notify the physician in a timely manner, and there was a lack of comprehensive assessment and intervention for the resident's deteriorating condition. Another resident with Alzheimer's disease and type 2 diabetes had a significant increase in blood glucose levels, with readings rising from a baseline range of 143-246 mg/dL to 399 mg/dL and then 521 mg/dL over several days. Staff failed to notify the physician when the resident's blood sugar first exceeded their baseline and reached critical levels in the 300s, only acting after the blood sugar reached 521 mg/dL, at which point the resident was transferred to the hospital and diagnosed with uncontrolled diabetes and metabolic encephalopathy. The resident's care plan and facility policy required monitoring and physician notification for significant changes in blood glucose, but these protocols were not followed. Interviews with staff confirmed that there was no clear parameter for physician notification and that earlier intervention could have potentially prevented the hospital transfer. Both cases demonstrate a lack of timely assessment, monitoring, and communication with the physician regarding significant changes in residents' conditions. The facility's failure to follow established care plans and policies for monitoring, documenting, and responding to changes in condition resulted in adverse outcomes for both residents, including hospitalizations for severe dehydration and uncontrolled diabetes.
Failure to Provide Pureed Bread as Required by Menu
Penalty
Summary
The facility failed to follow the prescribed menu for residents on pureed diets, as observed during meal service. On the specified date, the menu included an oven roasted turkey with gravy, sweet potatoes, Brussel sprouts, dinner roll, chilled peaches, and beverages. However, all residents receiving pureed diets did not receive a bread or roll item with their meal, despite the menu and available recipes for pureed bread. Staff interviews confirmed that pureed bread was not provided because the facility did not have the bread puree mix, and it had not been prepared for some time, even though recipes were available. This deficiency affected all seven residents on pureed diets in the sample reviewed.
Failure to Address Call Light Delays and Inconsistent Refrigerator Policy Enforcement
Penalty
Summary
The facility failed to address concerns raised by a resident and their family regarding excessive call light response times and inconsistent enforcement of a new policy prohibiting personal refrigerators in resident rooms. One resident and their family reported that it often took 45 minutes or more for staff to respond to call lights, particularly on weekends, and that these concerns were communicated to the DON but not formally documented or addressed. The family was not offered an opportunity to complete a concern form, and the DON did not consider the conversation a formal complaint because the family did not use specific language indicating a concern. Additionally, the facility recently implemented a policy to remove personal refrigerators from resident rooms, citing safety concerns such as expired food and wandering residents accessing food not intended for them. However, this policy was not applied consistently, as one resident's refrigerator was removed while another resident still had a refrigerator in their room. Staff confirmed that some residents continued to have personal refrigerators because the facility had not yet educated all families about the new policy. There was no documentation that the affected resident or their family received education about the change. The facility's own policies require timely response to call lights and guidance for safe storage of personal food, but these were not followed as documented in the report. The lack of consistent communication, documentation, and enforcement of policies resulted in unequal treatment of residents and failure to honor their rights to dignity, self-determination, and communication.
Call Light Not Placed Within Resident's Reach
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's Call Light Response policy by not ensuring that a resident's call light was within reach. During an observation, the resident was found in a Geri chair on the right side of the bed, calling out for help and requesting to be put back to bed, as well as looking for his dentures. The call light was observed to be placed on the upper head part of the bed, out of the resident's reach. This was confirmed by a CNA/Restorative Aide, who then moved the call light closer to the resident. The Director of Nursing later confirmed that staff are expected to place the call light within reach, especially after returning a resident from dialysis, in accordance with the facility's policy.
Failure to Obtain Proper Consent for Video Monitoring in Shared Room
Penalty
Summary
The facility failed to maintain the privacy and dignity of two residents by not properly obtaining informed consent for placement in a semi-private room where video monitoring was in use. Signage indicating video monitoring was observed on the residents' room doorway. The administrator stated that consent is obtained when a roommate is placed in a room with video monitoring, but documentation and interviews revealed inconsistencies in the consent process. For one resident, the social services staff provided a newly signed consent form after the original was given to the surveyor, and this new form was placed in the electronic medical record (EMR) only recently. There was also a lack of clarity regarding why the consent was not uploaded into the EMR at the appropriate time. One of the residents involved had a BIMS score indicating moderate cognitive impairment and had a power of attorney (POA) in place. The social services staff stated that verbal consent was obtained from the POA, but there was no documentation in the medical record to support this between the time of the voicemail left for the POA and a later note. The staff also indicated that they did not believe written informed consent from the POA was necessary for video monitoring, as it was not related to healthcare. This lack of proper documentation and failure to obtain and record informed consent from the appropriate decision-maker resulted in a breach of privacy and confidentiality requirements.
Failure to Develop and Document Comprehensive Skin Breakdown Prevention Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address and prevent skin breakdown for a resident with multiple risk factors, including diabetes, dementia, anemia, end stage renal disease, sacral pressure ulcer, and dependence on renal dialysis. Upon readmission from the hospital, the resident was not provided with a thorough skin assessment to document the size and appearance of existing wounds or dressings. The initial care plan did not include specific interventions to prevent further skin breakdown, and updates to the care plan were not documented until much later. Observations and interviews revealed that the wound nurse and LPNs were unclear about the presence and documentation of wounds on the resident's legs upon readmission. The wound nurse stated that she was not present at the time of readmission and relied on the admitting nurse's assessment, which only noted scars and not open wounds. There was no documentation or photographic evidence of the resident's skin condition at the time of readmission, and the use or frequency of preventive interventions such as heel protectors was not recorded. The treatment administration record did not show any treatments for the resident's legs on the day of readmission. Facility policies required comprehensive skin assessments and person-centered care planning, but these were not followed. The lack of clear documentation and timely assessment led to uncertainty about the resident's skin status and the interventions in place to prevent further breakdown. The wound doctor later confirmed the presence of pressure ulcers on both lower legs, distinguishing between scars and scabs, and noted that a pressure ulcer can develop in a short period. The failure to follow policy and document interventions affected the resident's care and did not meet regulatory requirements for comprehensive care planning.
Failure to Complete Comprehensive Skin Assessments and Ensure Proper Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow its own policies regarding comprehensive skin assessments and pressure ulcer prevention for two residents with skin impairments. Upon readmission from the hospital, one resident with multiple diagnoses including diabetes, dementia, end stage renal disease, and a history of pressure ulcers did not receive a comprehensive skin assessment to identify the size and appearance of wounds or dressings present. Documentation was lacking for the presence and frequency of preventive interventions such as heel protectors, and there was no evidence that a low air loss mattress was used according to manufacturer recommendations. The wound nurse and LPN provided conflicting accounts regarding the condition of the resident’s legs upon readmission, with the wound nurse identifying open pressure ulcers and the LPN documenting only scars. No skin pictures were taken at the time of readmission, and the treatment administration record did not show any treatments for the resident’s legs on the day of readmission. Another resident, admitted with a stage 3 pressure ulcer to the sacrum and identified as high risk for skin breakdown, was observed on a low air loss mattress. However, the mattress was not set according to the resident’s actual weight, as required by manufacturer guidelines and facility policy. The resident’s weight was significantly lower than the mattress setting, and although staff stated that checks are performed to ensure correct settings, the observation revealed a discrepancy. The care plan for this resident included interventions for pressure ulcer prevention, but the implementation did not align with the operational manual for the mattress. Facility policies required comprehensive, person-centered care planning and specific interventions for residents at risk for skin breakdown. The lack of documentation, incomplete assessments, and failure to ensure proper use of pressure-relieving equipment contributed to the deficiencies identified by surveyors. These actions and inactions resulted in the facility not providing appropriate pressure ulcer care and not preventing new ulcers from developing, as required by their own policies and procedures.
Lack of Documented Diagnosis for Indwelling Catheter
Penalty
Summary
Surveyors found that the facility failed to document a diagnosis or indication for the use of an indwelling catheter for one resident. During observations, a resident was noted to have an indwelling catheter in place. Review of the resident's physician order sheet showed an order for the catheter, specifying the size and balloon volume, but the section for diagnosis or reason for the catheter was left blank. The Director of Nursing confirmed that a diagnosis should be documented on the physician order to indicate the reason for the indwelling catheter. The facility's own policy also requires that physician orders specify the diagnosis or indication for use, but this was not followed in this case.
Failure to Accurately Document Meal Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to accurately document meal intake for two residents who were being monitored for nutrition. Observations showed that both residents consumed only 25% of their lunch meal, yet documentation in the point of care system indicated that one resident had consumed 76-100% of the meal. Staff interviews confirmed that CNAs are responsible for documenting meal intake after each meal and are expected to notify nursing staff if a resident eats very little or nothing. However, the Director of Nursing was unable to provide complete meal intake documentation for the past three months for either resident, and review of records showed missing documentation for multiple meal opportunities. Both residents had documented histories of significant weight loss over several months, with one resident experiencing a decrease from 181 to 146.6 pounds and the other from 93 to 80 pounds. The registered dietitian and interdisciplinary team had initiated weekly weights and nutritional interventions, including supplements and appetite-stimulating medication, due to ongoing weight loss and decreased oral intake. Despite these interventions, the lack of accurate and complete meal intake documentation hindered effective monitoring and response to the residents' nutritional needs.
Failure to Ensure Timely Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that residents received face-to-face visits from their attending physicians within the required timeframes, as outlined in the facility's physician services policy. Specifically, one resident was admitted and did not have a documented face-to-face physician visit until 20 days after admission, with no further visits recorded, despite subsequent hospitalizations and returns. Another resident had only sporadic face-to-face visits documented, with significant gaps between visits and no evidence of compliance with the required frequency. The attending physician stated that he is present in the facility several times a week and documents visits in the electronic medical record, but the records reviewed did not support that the required visits occurred as per policy. The facility's policy requires a physician to see Medicare residents at least every 30 days and all other residents at least every 60 days, with documentation of each visit in the medical record.
Failure to Assist Resident with Transportation for Medically Necessary Eye Appointment
Penalty
Summary
A resident with macular degeneration and impaired vision was not assisted by facility staff in obtaining transportation to a retinal specialist appointment, as ordered by the physician and recommended by an ophthalmologist. The resident reported having to cancel the appointment due to the high cost of transportation and stated that no alternative options, such as seeing the in-house eye doctor, were offered. Staff interviews confirmed that only one transportation company was contacted, and when the resident declined to pay the out-of-pocket cost, no further alternatives or education about other options were provided. Documentation did not reflect any education given to the resident regarding transportation responsibilities or any efforts to arrange alternative transportation. The facility's policy requires staff to arrange transportation for outside appointments unless the family chooses to do so, and to reschedule missed appointments at the earliest time. However, staff did not document any attempts to reschedule the appointment or offer other solutions after the resident declined to pay for the transportation. The care plan indicated the need for ongoing ophthalmology consults, but there was no evidence that the facility followed through with these interventions for the resident after the initial appointment was missed.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer prescribed medications as ordered for two residents. One resident with a diagnosis of hematuria did not receive the scheduled 9AM dose of Midodrine 5mg, a medication used to increase blood pressure, because the medication was not available in the pyxis or cycle med roll. The nurse identified the missing medication, contacted the pharmacy, and notified the physician, but the medication was not administered until 10:59AM, nearly two hours after the scheduled time. The resident's blood pressure was documented as low prior to the scheduled dose, and the delay was confirmed through nursing notes and the medication administration record. Another resident with macular degeneration did not receive the scheduled 9AM dose of prednisolone acetate ophthalmic suspension 1% eye drops, which are ordered four times daily to relieve eye pressure. The nurse did not administer the medication because the resident was in the dining room, and facility policy did not allow medication administration in that setting. The nurse subsequently decided to skip the 9AM dose and planned to administer the next scheduled dose early. The medication administration record confirmed the 9AM dose was not given, and the resident reported feeling increased pressure in the eyes due to the missed dose.
Failure to Remove Expired Medications and Improper Storage of Lorazepam
Penalty
Summary
The facility failed to ensure proper medication management in several instances. During a review of the medication cart, a 12-count card of ferrous sulfate 325mg tablets with an expiration date of 03/2025 was found in the cart after the expiration date had passed. The nurse responsible for the cart admitted that expired medications should be removed immediately and that it is the nurse's responsibility to check for expired medications before the morning medication pass, but confirmed that this check had not been performed. The expired medication was only removed after it was pointed out during the review. Additionally, three bottles of oral liquid Lorazepam, which require refrigeration according to the manufacturer’s label, were found stored in the narcotic box of a medication cart instead of in the refrigerator. The LPN present was unaware of the storage requirements, and only after consultation with the ADON was it confirmed that the medication should be refrigerated. Furthermore, a bottle of Lorazepam for a resident whose order had been discontinued was still present in the medication cart, contrary to facility policy that requires discontinued medications to be disposed of the same day. The facility’s policy and the medication insert both specify the need for proper storage and prompt removal of expired or discontinued medications.
Failure to Follow Contact Isolation Protocols for Resident with ESBL/VRE Infection
Penalty
Summary
Staff failed to follow the facility's transmission-based precautions policy for a resident with a documented ESBL/VRE urinary tract infection who was under contact isolation. On two separate occasions, staff entered the resident's room without donning the required personal protective equipment (PPE). One CNA entered the room with only a surgical mask, did not wear gloves or a gown, and did not perform hand hygiene before entry, despite signage indicating contact isolation. The CNA handled items in the room and assisted the resident with a meal before exiting and using hand sanitizer. The CNA stated they were unaware of the type of isolation required for the resident. A nurse also entered the same resident's room wearing only gloves, omitting the gown as required by the posted contact isolation sign. The nurse was unable to confirm the resident's current isolation status and stated confusion regarding whether the resident was on contact isolation or enhanced barrier precautions. The infection prevention nurse later confirmed that the resident was on contact isolation and that staff are expected to don gown, mask, and gloves prior to entry. The resident's care plan did not address contact isolation, despite physician orders and infectious disease notes specifying the need for such precautions.
Failure to Complete Comprehensive Metabolic Panel as Ordered
Penalty
Summary
The facility failed to follow physician orders to complete a comprehensive metabolic panel (CMP) for a resident diagnosed with multiple complex conditions, including Ogilvie syndrome, cerebral palsy, and severe intellectual disabilities. The physician orders, dated from 10/15/24 to 10/30/24, specified the need for a CMP and other lab tests to be conducted on specific dates. However, these tests were not completed as ordered, and the facility was unable to present lab results for the CMP on the specified dates. The Director of Nursing (V2) was initially unaware of the missed lab draws until informed by the Nurse Practitioner, and upon review, it was found that the specimen collected was insufficient to run the test. The resident's care plan required skilled services, including lab monitoring, due to their complex medical history and current health status. Despite the facility's policy on physician orders, which includes the administration of drugs and diagnostic orders upon a clean, complete, and signed order, the CMP was not completed. The Director of Nursing confirmed that the issue was not with the contracted laboratory, indicating a failure within the facility's processes to ensure the completion of necessary diagnostic tests as per physician orders.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to implement effective fall interventions for a resident, resulting in the resident walking unassisted, falling, and sustaining a left hip fracture. The resident, primarily Spanish-speaking with dementia, exhibited poor safety awareness, impulsive behaviors, and an unsteady gait, requiring one-person assistance and an assistive walking device. Despite being identified as a high fall risk, the resident was left unsupervised in a common area when a CNA left to provide care for another shift, leading to the fall. Interviews with staff revealed that the resident was known to be impulsive, often attempting to get up and walk without assistance, and becoming combative when redirected. The CNA responsible for supervising the resident had informed a nurse of her intention to leave the common area to perform rounds, but the nurse was occupied with medication administration and did not ensure continued supervision. Consequently, the resident was found on the floor by the nurse after a fall. The resident's admission and fall risk evaluations confirmed her high risk for falls, with a score significantly above the threshold. The facility's fall prevention policy emphasizes the importance of identifying at-risk residents and implementing preventative strategies, yet the resident's care plan was not adequately adjusted to prevent the fall. The incident was reported to the state, and the resident was hospitalized with a left hip fracture requiring surgical intervention.
Failure to Supervise High Fall Risk Residents and Use Appropriate Equipment
Penalty
Summary
The facility failed to supervise a resident identified as a high fall risk, who has a diagnosis of Dementia, Syncope, and a history of falls. This resident, while sitting unattended in the dining room, experienced an unwitnessed fall from her wheelchair, resulting in a left hip fracture. The incident occurred when no staff was present in the dining room to monitor the resident, despite her care plan indicating a high risk for falls and the need for supervision. The resident was later found on the floor by a CNA, and emergency services were called to transport her to the hospital for evaluation and treatment of the fracture. Another resident, diagnosed with Dementia, Alzheimer's disease, and Anxiety, fell from her wheelchair while being transported without leg rests. The resident was holding her feet up off the ground, but her foot eventually dropped and gripped the floor, causing her to fall forward and sustain a right forehead hematoma. The CNA who was pushing the wheelchair confirmed that leg rests were not used during the transport, despite their availability and the resident's care plan indicating the need for such equipment to prevent falls. Both incidents highlight the facility's failure to adhere to its fall prevention and management policy, which aims to maximize residents' well-being by identifying those at risk for falls and implementing preventive strategies. The lack of supervision and failure to use appropriate equipment directly contributed to the falls and subsequent injuries of the two residents involved.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to have a system to track requests for diagnostic services, resulting in a significant delay in providing timely x-ray services to a resident. The resident, who had a history of syncope, unsteadiness on feet, orthostatic hypotension, restless leg syndrome, unspecified dementia, and anxiety disorder, reported a fall and subsequent pain in his left side. Despite the resident's report of severe pain and a physician's order for a chest x-ray, the x-ray was not performed within the expected 24-hour timeframe, leading to the resident being transported to the hospital after waiting over 30 hours for the x-ray service. The hospital diagnosed the resident with multiple rib fractures upon arrival. The facility's documentation and communication regarding the x-ray order were inadequate, contributing to the delay. The nurse on duty notified the doctor and received an order for a chest x-ray, but the x-ray service did not arrive within the expected time. The resident and his family repeatedly inquired about the x-ray, and the facility staff made follow-up calls to the x-ray company, but the technician did not arrive until after the resident had already been sent to the hospital. The facility's Director of Nursing (DON) and the x-ray technician confirmed that the x-ray should have been completed within 24 hours, and there was no documentation of follow-up communication from the facility to ensure the x-ray was performed in a timely manner. The resident's physician order sheets did not document any order for a chest x-ray, further indicating a lack of proper tracking and communication within the facility. The hospital records confirmed the resident's pain and the delay in receiving the x-ray, ultimately diagnosing the resident with acute left lateral seventh and eighth rib fractures. The facility's in-service packet for x-ray services stated that non-stat orders should be performed the same day, but this protocol was not followed in this case.
Failure to Follow Sanitizing Guidelines
Penalty
Summary
The facility failed to follow sanitizing guidelines and manufacturer's instructions by not sanitizing a knife and cutting board for the required 1 minute. This deficiency was observed when a cook sanitized a knife and cutting board by submerging them in the sanitizer for only 1 second. Both the Regional Dietary Manager and the Dietary Manager confirmed that items should be sanitized for 1 minute according to the manufacturer's guidelines and facility policy. This failure has the capacity to affect 104 residents receiving an oral diet at the facility.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays, affecting seven out of seven residents reviewed for residents' rights in a sample of 26. During a resident council meeting, multiple residents stated that they do not receive mail on Saturdays and have to wait until Monday. An interview with the Life Enrichment/Activities staff revealed that Saturday's mail is placed in a locked administration office by the receptionist, and activity aides do not have access to this office. As a result, mail is only distributed to residents on Mondays. The facility's document on resident rights indicates that residents have the right to unimpeded, private, and uncensored communication by mail, phone calls, and with visitors, unless restricted by a physician for safety reasons.
Failure to Immediately Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to follow their abuse policy by not immediately reporting a bruise of unknown origin on a resident to the immediate supervisor or the administrator. The resident, who was admitted with diagnoses including hypertension, depressive disorder, hemiplegia, and respiratory failure, had a bruise on her hand reported by her sister. The resident stated that a staff member caused the bruise by squeezing her hand during care. The nurse documented the incident and notified the administration immediately. However, the investigation revealed that the bruise was noticed by staff members on different occasions prior to the official report, but it was not reported immediately as required by the facility's abuse policy. One CNA noticed the bruise on the resident's hand but did not report it because she was unsure of its cause and the resident did not respond when asked about it. Another CNA confirmed that the resident had a bruise on her hand and mentioned it to the nurse, but the incident was not reported immediately. The facility's abuse policy mandates that any suspicious bruises or abnormalities of unknown origin must be reported to the administrator or an immediate supervisor immediately, which was not followed in this case.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family of a resident's change of condition. Specifically, a resident was sent to the hospital, and the family member was not informed. During an interview, the family member stated that they were not informed about the resident's hospitalization. The Director of Nursing confirmed that staff are expected to notify the family of any change in the resident's condition, even in emergencies. A review of the resident's progress notes and assessments did not show any notification made to the family member. The facility's policy on Change in Resident Condition requires communication with the resident and their responsible party to be documented in the resident's medical record or other appropriate documents.
Failure to Provide Secure Storage for Resident's Money
Penalty
Summary
The facility failed to ensure a resident identified as at risk for abuse was free from misappropriation of property by not providing a secure location for the resident to store his money. This resulted in the resident having four hundred dollars stolen while in the facility. The resident, diagnosed with aphasia following a cerebral infarction, was assessed to be alert and reported the theft. The resident stated that his wallet, containing the money, was left on the window sill in his room. The resident saw a staff member in his room but was unable to provide a complete description due to his communication challenges. The facility did not provide any means for residents to secure their personal items, and the resident's family was not informed about the need for a lockbox. Staff interviews revealed that the resident had been showing his money to others before reporting it stolen. The facility's administrator confirmed that they do not provide secure storage for residents' personal items and suggested that families bring a lockbox if needed. The social service staff and other CNAs corroborated the resident's report of missing money and noted that the resident had a significant amount of cash in his wallet. The facility's abuse policy affirms the right of residents to be free from misappropriation of property, but in this case, the lack of secure storage led to the resident's loss of money.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,714 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palos Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victorian Village Hlth & Well | 2.7 mi | ★★★★★ | 1 | 0 |
| Lemont Nursing & Rehab Center | 3 mi | ★★★★★ | 27 | 0 |
| Franciscan Village | 3.2 mi | ★★★★★ | 14 | 0 |
| Warren Barr Orland Park | 4.3 mi | ★★★★★ | 3 | 0 |
| Harmony Palos | 5.1 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.