F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
Based on observation, interview, and record review the facility failed to follow their Medication
Administration Policy by not notifying the physician that a resident's anti-seizure medications were not
available in a timely manner. This failure resulted in R10 having a seizure the next morning and being sent
out to the hospital. This failure affected 1 (R10) of 3 residents reviewed for Quality of
Care/Treatment.Findings include: On 2/18/2026 at 3:09PM, V2 (DON-Director of Nursing) stated pharmacy
notified the DON the delivery hours for medication had a cut off time after 4:00PM on 12/24/2025 due to the
holiday. V2 stated the facility nurses use the (medication dispensing system) machine to retrieve
medications that have not been delivered from the pharmacy and are given to the residents as ordered by
the doctor. V2 states if the medication is not available in the (medication dispensing system) machine the
nurse should call and notify the doctor and family, but R10's nurse did not notify V35. V2 stated Dilantin was
the only anti-seizure medication in (medication dispensing system) out of the 3 anti-seizure medications
R10 takes for the seizure diagnosis. V2 states R10 was given Dilantin pulled from (medication dispensing
system) the next day on 12/25/2025.On 2/19/2026 at 12:38PM, V35 (Nurse Practitioner) states on
12/24/2025 around 6:00PM, V35 was notified by R10's nurse of R10's admission into the facility. V35 stated
he was not notified that the facility did not have 2 of R10's seizure medications in the (medication
dispensing system) machine. V35 stated he was unaware of the pharmacy's cut-off hours because of the
holiday. V35 stated R10's nurse did not call V35 on 12/24/2025 in the late evening to notify V35 that R10 did
not take any of her anti-seizure medications. V35 stated if he was notified that R10's anti-seizure
medications were not delivered and R10 did not take any anti-seizure medications the evening of
12/24/2025, V35 stated he would have placed an order to send R10 back to the hospital that same
night.Record Review of R10's December 2025 Medication Administration Record (MAR) Topiramate Oral
Tablet 200 MG give 1 tablet by mouth two times a day for Epilepsy , Phenytoin Sodium (Dilantin) Extended
Capsule 100 MG give 2 capsule by mouth two times a day for Epilepsy, Oxcarbazepine Oral Tablet 600 MG
give1200 mg by mouth two times a day for Epilepsy, were not administered on 12/24/2025 as instructed by
R10's Hospital Discharge Medication list.Record review of R10s progress note dated 12/25/2025 at
9:55AM, documents V23 (R10's concerned party) insisted R10 go out 911 because R10 had a
seizure.Record review of R10s progress note dated 12/25/2025 at 4:45PM documents R10 was admitted to
(local) Hospital with seizure activity.V2 stated the evening of 12/25/2025, V2 provided an in-service to the
nurses. The topic states when a new admission arrives to the facility and medications are not available,
nurses are to attempt to pull from (medication dispensing system) and if not in the (medication dispensing
system) notify MD (physician) and get an order to give medication upon arrival. State Surveyor observed
the in-service /meeting is signed by nurses and dated 12/25/2025.On 2/18/2026 at 12:16PM, V20 (Former
Administrator), states if family notifies her of a concern V20 would have addressed it right away or informed
the DON right away.During Observation, on 2/19/2025, Surveyor and V2 reviewed the list of medications
available on the
Residents Affected - Few
(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
02/20/2026
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 0684
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
(medication dispensing system) machine, only Phyentoin100mg capsule was available, but V2 stated it was
not given to R10 until 12/25/2025. V2 stated the nurse did not notify V35 the evening of 12/24/2025 that the
anti-seizure medications were not given.V2 provided R10s Hospital Discharge Medications, documents
topiramate 200mg tablet (Take 200mg by mouth in the morning and 200mg in the evening) dose was given
on 12/24/2025 at 8:23AM in the hospital, next scheduled dose in the evening time at 11:00PM. Hospital
Discharge Medication Documents Phenytoin 100mg ER capsule (Take 200mg by mouth in the morning and
200mg in the evening) last dose 200mg on 12/24/2025 at 8:24AM, next scheduled dose for 11:00PM.
Hospital discharge medication Oxcarbazepine 600mg tablet (Take 1,200mg by mouth in the morning and
1,200mg in the evening) last dose 1,200mg on 12/24/2025 at 8:23AM, next scheduled dose
11:00PM.During record review no progress note was written by R10's nurse to notify V35 that R10's
antiseizure medications were not delivered and R10 was not given any of R10's anti-seizure medications
the evening of 12/24/2025 as directed by the hospitals discharge medication list scheduled time.Facility
Policy Titled Medication Administration Review date 5/2025, documents: General: Medications are
administered safely and appropriately to aid residents to overcome illness relieve and prevent symptoms
and help in diagnosis.Guideline:22. If medication is not given as ordered document the reason on the MAR
(Medication Administration Record) and notify the health care provider.26. If the medication is ordered but
not present check to see if it was misplaced and then call the pharmacy to obtain the medications. If
available obtain it from the contingency or convenience box27. If the physician's order cannot be followed
for any reason the physician should be notified in a timely manner depending on the situation and a note
should reflect the situation in the residence medical record.
Event ID:
Facility ID:
145681
If continuation sheet
Page 2 of 2