Inspection·July 17, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that medication orders received include a prescribed dose, and failed to maintain a medication error rate below 5%. There were 4 medication errors out of 37 opportunities, resulting in a 10.81% medication error rate. Three of three residents (R7, R10, R12) in the medication administration sample were affected. Findings include:1.R10's POS (Physician Order Sheets) include Escitalopram 20mg (milligrams) give 1 tablet one time a day. Special instruction: take with 10mg tablet for total dose of 30mg daily (start date: 11/21/24).On 7/15/25 at 8:30am, V11 (LPN/Licensed Practical Nurse) dispensed (1) 20mg Escitalopram tablet in R10's medication cup (with scheduled 8am medications) and affirmed she was prepared to administer them however R10's prescribed Escitalopram dose is 30mg. Surveyor inquired how much Escitalopram was dispensed in R10's medication cup V11 checked the single dose package and affirmed it was 20mg. Surveyor inquired what R10's Escitalopram order states V11 accessed R10's EMAR (Electronic Medication Administration Record) and stated, Escitalopram 20 milligrams give 1 tablet 1 time a day and take with a 10-milligram tablet. Surveyor inquired about R10's Escitalopram prescribed dose V11 responded 30 milligrams. 2. R7's POS includes Aspirin 81mg (Chewable) tablet daily (start date: 5/2/25).On 7/15/25 at 8:57am, V3 (LPN) dispensed (1) Aspirin EC (Enteric Coated) 81mg tablet in R7's medication cup (with scheduled 9am medications) and affirmed she was prepared to administer them. Surveyor inquired about R7's dispensed Aspirin V3 inspected the Aspirin container and stated, 81 milligrams of Aspirin it says low dose pain reliever enteric coated. Surveyor inquired which Aspirin was prescribed for R7 V3 accessed R7's EMAR and responded, 81 milligrams chewable.3. R12's POS includes Calcium Carbonate-Vitamin D 600-10mg-mcg (micrograms) daily (start date: 5/18/25) and Lactobacillus 1 capsule daily (start date: 5/21/25) however the prescribed dose is excluded. On 7/15/25 at 9:30am, V12 dispensed (1) Calcium Carbonate 500mg tablet in R12's medication cup (with scheduled 9am medications) and affirmed she was prepared to administer them. Surveyor inquired about R12's Calcium Carbonate orders V12 accessed R12's EMR and stated, It says 600 milligrams, it's 600 milligrams. Surveyor inquired again about R12's Calcium Carbonate orders V12 responded Its calcium carbonate with vitamin D, I don't have that one. V12 also dispensed (1) Lactobacillus 1 billion CFU capsule in R12's medication cup and administered this medication however R12's Lactobacillus orders exclude a dose. Surveyor inquired about R12's prescribed Lactobacillus dose (after administration) V12 accessed R12's EMAR and stated, ‘It's just give one capsule. The (1/2023) medication administration policy states an order is required for administration of all medication. Check medication administration record prior to administering medication for the right medication, dose, route, resident, and time. If there's a discrepancy between the MAR and label, check orders before administering medications. Verify that no contradictions exist. Residents Affected - Few 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 3 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 07/17/2025 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)