Inspection·July 3, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide incontinence care timely for a resident who was identified as dependent on staff. This affected one of three residents (R2) reviewed for incontinence care. Residents Affected - Few Findings Include: R2's minimal dated set (MDS) section C brief interview for mental status dated 6/27/25 documents: a score of fifteen which indicates cognitively intact. Section H (bowel/bladder) dated 6/30/25 documents: frequently incontinence. Section GG (functional ability) documents: toileting- dependent. R2's Minimum Data Set, dated [DATE] documents: roll left and right. The ability to roll from lying on back to left and right side and return to lying on back ln the bed documents substantial/maximal assistance. On 7/1/25 at 10:48pm, R2 who was assessed to be alert and oriented to person, place and time said, she was left soiled and saturated with urine for 3.5 hours on one occasion and over two hours on another. R2 said, being left in saturated urine made her feel stressed, frustrated and concerned with her safety because she would have to let one person change her instead of the required two person assist. On 7/3/25 at 11:53am, V18 (cna- certified nursing assistant) said, when she reported to work on the day shift (unknown date), R2's call light was on. V18 said, she went into R2's room. R2 stated, she needed to be changed and her call light had been on for over an hour. R2 was visibly upset. V18 said, she looked for R2's overnight assigned aide and could not find that staff member. V18 said, she provided incontinence care for R2. V18 said, R2 was soiled and saturated with urine. V18 said, R2's sheets were also saturated with urine. V18 said, R2 was not a heavy wetter. V18 said, the amount of urine on R2 and her bed linen was consistent with not being changed overnight. V18 said, she does not recall the date but R2 was observed soiled and saturated on a different day as well. V18 said, she provide incontinence care for R2 twice when she was left soiled and saturated with urine on two separate dates. V18 said, residents should be checked and changed every two hours. An Email written by R2 documents: June 23, 2025: R2 waiting three in a half (3.5) hours to get changed this morning. R2 was left soiled with a wound. The nurse refused to assist the cna with changing R2 until R2 asked her why can't she help. June 22, 2025: R2 wrote she has been waiting since 5:30 am to be changed. Once again another cna left R2 soiled. It's now 7:45am. June 21, 2025: During both shifts R2 sat soiled in urine. The 7am-3pm. R2 waited two (2) hours for assistance. One excuse was it was the cna sitting time. R2 was also told it's only one cna helping everybody on this hall. The next shift, R2 waited almost two (2) hours to get put in bed, changed and a bed bath. (continued on next page) 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 07/03/2025 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)