F 0559
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice
before a change is made.
Based on interview and record review the facility failed to follow their policy and provide a written notice of
room change with and explanation of the room change for one of one resident (R2) reviewed for written
room change notice.
Findings include:
On 2/27/25 at 10:39am V1 (R2's sister/ POA-Power of Attorney) said the facility did not discuss R2's room
change with her. V1 said she did not get a copy of the room change notice.
On 2/27/25 at 4:40pm request was made to V4 (Director of Nursing) V5 (Administrator) and V7 (Social
Service) to review the written notice of room change for R2.
On 2/28/25 upon exit of this survey V5 (Administrator), V4 (Director of Nursing), and V7 (Social Worker) did
not present a copy of the written notice of room change and explanation of room change for R2, the facility
did not present documentation denoting a written notice was given to R2's family/poa/ resident
representative
Facility policy dated 11/1/2023 denotes in-part room change/transfer within facility. To assure residents and/
or their representatives are appropriately notified of room transfers and that the room's occupants are
notified that they will be receiving a new roommate. When a resident is being moved to a new room at the
request of the facility, the residents, family or resident representative shall receive an explanation in writing
of why the move is required. The resident will be provided the opportunity to see the new location, meet the
new roommate, and ask questions about the move.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145681
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aliya of Crestwood
13259 South Central Avenue
Crestwood, IL 60418
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interview and record review the facility failed to follow their abuse prevention policy and report an
allegation of abuse to the abuse coordinator and or Director of Nursing on 2/21/25 for one of one resident
(R1) reviewed for abuse reporting.
Findings include:
R1 face sheet denotes R1 has diagnosis of dementia.
On 2/27/25 at 4:19 pm V3 (Registered Nurse) said V1 (visitor) approached him on 2/21/25 and said that V2
(Certified Nursing aide/CNA) slapped R1 on the knee. V3 said he did not report the allegation to V4 (DON)
or V5 (Administrator).
On 2/27/25 at 4:25 pm (Director of Nursing) said he was not aware of the allegation of abuse for R1.
Facility policy titled abuse prevention dated 3/2022 denotes in-part, internal reporting requirements and
identification of allegations. Employees are required to report any incident, allegation or suspicion of
potential abuse, neglect, exploitation, mistreatment of resident property they observe, hear about, or
suspect to the administrator immediately, to an immediate supervisor who must then immediately report it
to the administrator or the compliance officer. In the absence of the administrator, reporting can be made to
individual who has been designated to act in the administrator's absence.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145681
If continuation sheet
Page 2 of 2
