Inspection·August 8, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is scheduled then the doctor must be notified so they are safe and aware of what is going on. V4 reported V4 begins morning med pass around 8AM. V4 stated V4 couldn't remember the exact time V4 first went in R1's room but R1 was not in the room. V4 reported it was sometime between 8-9AM. V4 stated V4 finished the med pass and went back to check but R1 was still not in the room. V4 reported R1 had family in the room but R1 was not in the room. V4 was unaware of what time R1 got back to the room. V4 denied looking for R1 throughout the facility. V4 stated V4 went to administer the 9AM medication around 2Pm but R1 refused to take the medication. V4 denied calling the physician about the missed medication. V4 reported the medications scheduled were some vitamins and gabapentin.On 8/6/25 at 12:06PM, V7 (Nurse Unit Manager) stated V7 was manager on duty for nursing that weekend but V7 was not in the building on 7/19/25. V7 reported being notified of the incident the next day by R1 during rounds. V7 stated V4 told V7 that R1 was out of the room during medication pass visiting with family. V7 reported getting a phone call but was unable to remember from who that the medication was never administered. V7 stated V7 instructed V4 to try to administer the medication sometime after 3:30PM after the second shift had started and to call and notify the doctor. V7 reported R1 told V7 the next day that R1 didn't take the medication because it was too close to the next scheduled dose. V7 stated R1 told V7 that r1 was only offered the medication once at 3PM. V7 reported the nurse should go look for the resident in the facility to offer the medication and put in a progress note on everything that happened. V7 stated the physician must be called to notify them of a missed dose. On 8/6/25 at 1:46PM, V10 (CNA) stated R1 gets out of bed everyday at 10:30AM. V10 denied ever getting R1 out of bed before 10:30AM. V10 reported R1 likes to sleep in until about 8-9AM so after finishing breakfast R1 is gotten ready for the day and transferred out of bed. V10 stated R1 has appointments out of the building R1 needs to be ready for by 10:30AM so that is the time staff always get R1 out of bed. V10 denied R1 being able to get out of bed without assistance. V10 reported if R1 has family in R1's room then R1 will be in the room as well visiting. V10 denied R1 being out of the room when family is visiting.A Nursing note dated 7/19/25 at 9AM documents the nurse attempted to give R1 medication but R1 was not in the room. The nurse will attempt to give medication when R1 returns.A Nursing note dated 7/19/25 at 4:11PM documents at the beginning of med pass, R1 was not in R1's room. Upon R1 returning to the room, R1 had family visiting. The nurse returned to R1's room to give the medication at the end of the shift. R1 refused and decided to call family to see if R1 should accept the medication.There are no progress notes that the nurse made any additional attempts to administer the medication other than at 9AM and did not notify the physician of the missed dose. The Physician Order Summary was reviewed and documents an order for duloxetine 40 mg once a day and gabapentin 100 mg cap twice a day.The Medication Administration Record dated 07/2025 documents R1 is scheduled vitamin B-1 tablet 100mg at 8AM once a day; multivitamin chewable tablet, collagen skin renewal tablet 833-30mg tablet, diclofenac sodium gel 1% to shoulders, duloxetine capsule 40 mg, and gabapentin capsule 100mg at 9AM, and gabapentin capsule 100mg capsule at 6PM. It is documented that R1 refused all medications at 8 and 9 AM. There is no pain score documented for 7/19/25 on the day shift.The Care Plan dated 3/31/25 documents R1 has an alteration in comfort related to a diagnosis of chronic pain syndrome. An intervention includes to administer pain medication and treatments as ordered.The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment).The Concern Form dated 7/21/25 documents R1 had questions/concerns with medication administration over the weekend. R1 reported being out of the room visiting family and did not receive morning medication. R1 reported the nurse came to the room at the end of the shift to offer medication but R1 refused due to it being too close to the next medication pass. The ADON educated R1 and V4 of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145681 If continuation sheet Page 2 of 3 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 08/08/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the five medication rights. R1 was informed that medication can be given one hour before and one hour after scheduled time.The policy titled, Medication Administration, dated 03/2025 documents, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline:.13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.22. If the medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. Event ID: Facility ID: 145681 If continuation sheet Page 3 of 3