Health inspection·February 20, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure proper integrity of the facility roof that resulted in ceiling cracks in two residents' rooms and ensure dust free ventilatory outlets in all residents' rooms throughout the facility. This failure has a potential to affect all 131 residents residing in the facility. Findings include: On 02/18/2025 at 09:45 AM Surveyor was provided with facility census listing 131 residents residing in the facility. On 02/18/25 between 11:00 AM and 2:00 PM Surveyor completed initial observations that revealed: - abundant collection of black/dark grey, powder like particles on the ceiling, around and in the ventilatory outlet and smoke detector in room [ROOM NUMBER] - cracked plaster on the ceiling with rusty discoloration in room [ROOM NUMBER], water collection bucket underneath the crack in the ceiling - cracked plaster on the ceiling with rusty discoloration in the bathroom room [ROOM NUMBER] - abundant collection of dark grey/white, powder like particles in the ventilatory outlets in every resident room throughout the facility On 02/19/25 between 10:00 AM and 01:00 PM Surveyor completed 2nd day observations that revealed: - abundant collection of black/dark grey, powder like particles on the ceiling, around and in the ventilatory outlet and smoke detector in room [ROOM NUMBER] - cracked plaster on the ceiling with rusty discoloration in room [ROOM NUMBER], water collection bucket underneath the crack in the ceiling - cracked plaster on the ceiling with rusty discoloration in the bathroom room [ROOM NUMBER] - abundant collection of dark grey/white, powder like particles in the ventilatory outlets in every resident room throughout the facility Page 1 of 6 145681 145681 02/20/2025 Aliya of Crestwood 13259 South Central Avenue Crestwood, IL 60418

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 02/19/25 at 11:14 AM Surveyor reveled abundant collection of black/dark grey, powder like particles on the ceiling, around and in the ventilatory outlet and smoke detector in room [ROOM NUMBER] and cracked plaster on the ceiling with rusty discoloration in room [ROOM NUMBER], water collection bucket underneath the crack in the ceiling to V25 (Maintenance), V25 said, Ceiling in the room [ROOM NUMBER] needs to be cleaned, it's dust. The dust heavily collected on the smoke detector, heating exhaust, and air return vent. It looks like it wasn't cleaned for a while. It is important to remove the dust for proper ventilation and proper smoke detector operation. There is roof leakage above room [ROOM NUMBER] that needs to be repaired. It's been like this for about three years. The roof needs to be patched. The yellow bucked underneath is to catch the water that gets through cracked ceiling. On 02/19/25 at 01:11 PM Surveyor reveled abundant collection of black/dark grey, powder like particles on the ceiling, around and in the ventilatory outlet and smoke detector in room [ROOM NUMBER] to V27 (Housekeeping Director), V27 said, It looks like it is dust (room [ROOM NUMBER]), it accumulated on smoke detector, outgoing vent air, and incoming air vent, and there is dark grey discoloration on the ceiling that needs to be painted but it is definitely not mold. The importance of cleaning off dust is that residents should not be breathing in type of debris that could cause potential health issues, such coughing, sneezing, or any other respiratory discomfort. Dusting of the ventilatory outlets should be done by housekeeping. Dusting was on the schedule for this week, and it should be done weekly. Dust observed in the room [ROOM NUMBER] would take at least 2-3 weeks to accumulate like that. Surveyor requested facility cleaning schedule to verify V's statement. On 02/19/25 at 02:11 PM V27 (Housekeeping Director) said, There is no cleaning schedule at this time, but I will create one for the future reference. On 02/19/25 at 03:31 PM V5 (Medical Director) said, Homelike environment in the facility is very important, especially that the residents consist of elderly population, often times demented. The homelike environment helps them stay stable and prevent exacerbation of aging process. Also, homelike environment helps residents to be more oriented to the surroundings, it goes along with residents' safety. Excessive dust may predispose residents to allergic reactions to dust or mold. Excessive dust could also exacerbate any preexisting respiratory conditions; therefore, residents' rooms should be well ventilated and free of dust. The facility Housekeeping guidelines (no date) reads in part, Purpose: To provide guidelines to maintain a safe and sanitary environment for residents, facility staff, and visitors. Standards: Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner. The Illinois Long Term Care Ombudsman Program Residents' Right for People in Long-Term Care Facilities (no date) reads in part, Your rights to safety: Your facility must be safe, clean, comfortable, and homelike. 145681 Page 2 of 6 145681 02/20/2025 Aliya of Crestwood 13259 South Central Avenue Crestwood, IL 60418

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to follow the pharmacy policy by not storing unopened Insulin in the medication refrigerator and documenting open date labels for three of three (R439, R127, R82) residents reviewed during medication storage and labeling in the sample of 32. Findings include: On 02/19/2025 at 12:15PM Surveyor conducted an inspection of the 1st floor (Unit 2-C) medication cart. Surveyor observed undated insulin pen medications not labeled opened, and unopened insulin not properly stored in facility/medication refrigerator for two residents: R439 Novolin R Flex Pen 100unit/ML - No open date written on label. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin should be refrigerated. R127 Lispro Kwik Pen 100unit/ML - No open date written on label. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin should be refrigerated. On 02/19/2025 at 12:50PM Surveyor conducted an inspection of the 1st floor (Unit 1-C) medication cart. Surveyor observed undated medication, opened insulin not properly labeled with an opened and expiration date for one resident: R82's Lantus Solo Injection Pen 100unit/ML - No opened and expiration date written on label. Facility Policy - 3.1: MEDICATION STORAGE IN THE FACILITY Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. R439's active physician order dated 01/27/2025 reads in part, Insulin NovoLIN R FlexPen 100 UNIT/ML Solution pen-injector, INJECT SUB-Q EVERY 6 HOURS PER SS: 150-200=1 UNITS; 201-250=2 UNITS; 251-300=3 UNITS; 301-350=4 UNITS; 351-400=5 UNITS; >400 CALL MD *CHART & ROTATE SITE*. R127's active physician order dated 01/17/2025 reads in part, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro INJECT SUB-Q BEFORE MEALS PER SS: 150 - 200 = 1 UNITS; 201 - 250 = 2 UNITS; 251 - 300 = 3 UNITS; 301 - 350 = 4 UNITS; 351 - 400 = 5 UNITS; CALL MD IF ABOVE 400 *CHART & ROTATE SITE* *HIGH ALERT DRUG*. R82's active physician order dated 11/22/2024 reads in part Lantus SoloStar 100 UNIT/ML Solution pen-injector, INJECT 20 UNITS SUB-Q AT BEDTIME. On 02/19/2025 at 12:15PM surveyor observed V15(Licensed Practical Nurse/LPN) on Unit 2 for Medication Storage and Labeling. During review of Med Cart known as Unit 2-C, R439's Novolin R Flex Pen 100ml insulin pen and R127's Lispro Kwikpen 100 unit/ml were unopened and not stored in the appropriate facility/medication refrigerator per pharmacy policy 3.5 Refrigerated Products. R439's and R127's unopened Insulin pen were not labeled with an open date as stated in Section 5 of the Refrigerated 145681 Page 3 of 6 145681 02/20/2025 Aliya of Crestwood 13259 South Central Avenue Crestwood, IL 60418

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Products Policy: Insulin Storage If unopened insulin is left at room temperature, the date opened would be the date it was sent from the pharmacy located on the prescription. V15(Licensed Practical Nurse/LPN) said she wasn't sure when the Insulin was received but said it should have been stored in the refrigerator until opened. V15(LPN) who said in summary, Insulin Pens are good for 28 days and need to be labeled with an open and expiration date. Surveyor observed original bag from pharmacy with residents' personal information, medication name, dosage, and storage instructions. Prescription bags are clearly labeled from pharmacy with a blue sticker store in fridge until opened. V15(LPN) confirmed the insulin pens were not labeled with an open date and was going to contact pharmacy for an expiration date. On 02/19/2025 at 12:50PM surveyor observed V16(Licensed Practical Nurse/LPN) on Unit 1 for Medication Storage and Labeling. During review of Med Cart known as Unit 1-C, R82's Lantus Solostar 100ml insulin pen was opened and not labeled with an open and expiration date. V16(LPN) who said in summary, Insulin Pens are good for 28 days and need to be labeled with an open and expiration date. Surveyor observed original bag from pharmacy with residents' personal information, medication name, dosage, and storage instructions. V16(LPN) confirmed the insulin pen was not labeled with an open and expiration date and was going to contact pharmacy. Surveyor interviewed V2 (Director of Nursing/DON) who said in the summary, it is important for the nurses to ensure both open and expiration dates are noted on the labels for insulin pens, per manufactures' guidelines to ensure drug safety and effectiveness. V2(DON) said unopened insulin pens should be stored in the appropriate facility/medication fridge until needed. V2(DON) said insulin pens should be individually labeled and stored in privacy bags and dated 28 days after opening so the medication can be discarded according to manufacturer's expiration date. Pharmacy policy 3.5: Refrigerated Products dated 07/2024 reads in part Medications required by the FDA to be stored in a refrigerator may be subject to special handling, storage, and record keeping: 2. Upon delivery, the nurse will be responsible for storing the medication in the appropriate facility/medication refrigerator. 5. Insulin Storage: all unopened insulin should be refrigerated. If unopened insulin is left at room temperature, the date opened would be the date it was sent from the pharmacy located on the prescription label. Expiration date for each insulin product varies, and facilities should refer to the insulin expiration date reference. Pharmacy Policy - 3.1: MEDICATION STORAGE IN THE FACILITY dated 07/2024 page 59: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. 145681 Page 4 of 6 145681 02/20/2025 Aliya of Crestwood 13259 South Central Avenue Crestwood, IL 60418

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to follow their policy and procedures for dietary food storage, cleaning, and hand hygiene practices by not ensuring stored foods were free of contaminated substances, not ensuring stored foods were properly labeled, not ensuring coolers and freezers were clean and free of contaminated items, not ensuring food items not intended for resident use were discarded, and not performing hand hygiene after handling contaminated items. This failure applies to all 123 residents receiving food from the facility. Findings include: On 02/18/2025 at 10:18 AM In the facility's main kitchen observed a strong foul odor in the cooler along with two large boxes of meat with a red substance spilled on them. V26 (Dietary Aide) stated she observed the strong odor, and it could be spoiled food or something spilled and the cooler needs to be cleaned. Observed a container with a burger patty labeled black bean burger partially covered with plastic wrap with no labeled dates. Observed a large box of tomatoes, a large box of lettuce, and a medium size box of cucumbers with no labeled dates. V26 stated the person who stocks the kitchen usually labels the food items. Observed five large containers containing dry cereals with no labeled dates. Observed a large unmarked/unlabeled can of food stored along with other canned foods. V26 stated the label is missing and they aren't sure what's inside of it. Observed more than 20 packages of bagels stored in a freezer with no labeled dates. Observed a one-pound pack of burger buns with no labeled dates. Observed two containers of sauce stored in the cooler with no labeled dates. V26 stated the sauces were likely from a party last week and needed to be thrown away. On 02/18/2025 at 10:43 AM In the facility's second smaller kitchen observed seven ham sandwiches stored in a cooler with only one sandwich labeled as being prepared on Monday and none of them included a labeled date. Observed several milk cartons stored in the cooler with an orange substance spilled on them. Observed two large salad dressing containers inside the cooler with dressing spilled over on the outside. Observed a pan in the cooler with multiple salad dressings stored on top of it with a large spot of orange dressing spilled on it. Observed a bin full of clean serving ladles with a sticky brown substance on the exterior. Observed a cereal dispenser containing cold cereals used during breakfast per V20 (Dietary Aide) with no labeled dates stored on a rack. V20 stated the cereal dispensers are usually labeled with a date on the front. Observed V19 (Dietary Aide) placing soiled dishes in the dishwasher, doff gloves and don a new pair without performing hand hygiene, then remove clean meal trays and silverware from the dishwashing area and place them with other clean items. On 02/19/25 at 11:46 AM V10 (Registered Dietitian) stated dietary staff should not transition from handling soiled dishes to clean dishes without performing hand hygiene and staff should wash hands between changing gloves. V10 stated if an odor is present in a cooler or freezer staff should check for old or expired foods, and if possible clear, deep clean and restart cooler or freezer. V10 stated all foods stored in the cooler or freezer should be labeled with at least a received by date and typically a used by date, so we know the shelf life and are not serving expired foods. V10 stated spilled substances observed on milk cartons should be cleaned immediately and they shouldn't be stored in that condition. On 02/19/25 at 3:06 PM V10 (Registered Dietitian) stated the bagels stored in the freezer did not have any clear dates labeled on them. 145681 Page 5 of 6 145681 02/20/2025 Aliya of Crestwood 13259 South Central Avenue Crestwood, IL 60418

F 0812 The facility's Food Storage Policy received 02/19/2025 states: Level of Harm - Minimal harm or potential for actual harm The purpose of the policy is to minimize contamination and bacteria. Food is stored in a clean safe sanitary manner that complies with the state and federal guidelines. Residents Affected - Many Containers for bulk items (flour, sugar, etc.) have tight fitting lids. Only food intended for residents should be stored in the kitchen food storage areas unless a specific area is assigned and maintained for outside items. Food should be dated upon receipt and stock rotated using first-in, first-out (FIFO) method. Food should be labeled and dated to monitor food safety. Food items in unmarked or unlabeled containers should be labeled with contents. Any food that is suspected of being contaminated or obviously contaminated should be discarded immediately. The facility's Kitchen Operations Policy for Cleaning and Sanitation received 02/19/2025 states: Kitchen staff should manually remove all excess food waste and obstacles from the surface/equipment. The facility's Hand Washing Policy received 02/19/2025 states: The purpose of the policy is food safety. Wash hand to remove contamination after handling soiled utensils or equipment, and after engaging in other activities that contaminate hands. 145681 Page 6 of 6