Aliya of Crestwood

Inspectors wroteBased on interview and record review, the facility failed to follow the resident's plan of care and accepted standards of practice for ostomy care by failing to monitor, measure, and document ileostomy output, resulting in lack of adequate nurse-to-provider communication, for one of one resident (R1) reviewed for ostomy care and services. This failure resulted in R1 having significant abdominal pain, being transported to the hospital, and diagnosed with a bowel obstruction.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their facility policies and protocols, failed to implement fall care plan interventions failed to follow basic life support/CPR protocol, failed to provide sufficient rounding/supervision to ensure resident's needs were met, and failed to provide care and services in accordance with professional standards of practice needed for one resident that required life sustaining services after experiencing a fall. The facility also failed to provide a working call light for one (R25) resident. These failures affected two (R4 and R25) of six residents reviewed for quality of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to staff the facility with a sufficient number of licensed nurses and nursing assistants to meet residents' needs, failed to staff the facility in accordance with the staffing needs/plan identified within the facility assessment, and failed to ensure sufficient staff were available to answer call light when one resident (R6) used the call light device to obtain help for his roommate (R4). The lack of sufficient staffing resulted in R4 self-ambulating, falling and experiencing a delay in care resulting in R4 sustaining major injuries. These failures affected one (R4) of seven residents reviewed for staffing and have the potential to affect all 145 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility's administration and quality assurance and performance improvement (QAPI) committee failed to make good faith attempts to correct known quality issues after a QAPI meeting was held in response to one resident's (R4) death, failed to disclose/provide QAPI committee records to the state survey agency to evaluate compliance with related QAPI regulations, failed to follow the facility's QAPI plan. These failures have the potential to affect all 145 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) committee's monitoring of systemic compliance identified deficient practices with quality of care, failed to identify systemic deficient practices with the facility's malfunctioning call light system, failed to identify systemic deficient practices with insufficient staffing, failed to identify systemically deficient practices regarding root cause analysis of incident investigation/reporting. Additionally, the facility's quality assurance processes failed to correct repeated history of non-compliance regarding professional standards of care, quality of care, functioning call lights, and infection control. These failures affect all 145 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the resident's right of confidentiality of their personal health information, failed to dispose of personal health information in a manner that renders the information unreadable, indecipherable and otherwise unreconstructable. This failure affected five (R14, R16, R17, R18, and R19) residents in a sample of five reviewed during medication administration and has the potential to affect all 34 residents that reside in the unit 2 assignment.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff were trained properly on CPR; failed to ensure staff initiated appropriate emergency response for a resident; failed to promptly activate Emergency Medical Services (EMS)/911 upon discovering an unresponsive resident; failed to accurately assess for the presence or absence of a pulse; and failed to perform uninterrupted cardiopulmonary resuscitation (CPR) for one (R4) of seven residents reviewed for cardiopulmonary resuscitation. These facility failures resulted in R4 not receiving uninterrupted CPR and emergency care prior to EMS arrival and has the potential to affect all 91 full code residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately sanitize reusable durable medical equipment between patient use, failed to perform hand hygiene before preparing medications for administration and failed to have accurate signage posted for isolation precautions (R17), These failures affected four residents (R14, R17. R18 and R19) and has the potential to affect all 34 residents who receive medications from unit one medication cart.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to administer subcutaneous injections in accordance with the facility's procedure for subcutaneous injections and in accordance with professional standards for subcutaneous injections. This failure affected one (R16) in a sample of five residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, facility failed to follow their medication administration policy and failed to ensure residents were free from significant medication errors. These failures affected one (R1) in a sample of six residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient operating call light system; and failed to ensure two resident's (R17 and R25) call lights were working properly. These failures affected two (R17 and R25) of 7 residents reviewed for call lights but have the potential to affect 145 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (R10) resident was free from unnecessary antipsychotic medication use, failed to ensure antipsychotic medication was not prescribed without adequate indication, and failed to document/identify targeted symptoms for antipsychotic use. These failures affected one resident (R10) in a sample of 72 residents reviewed for unnecessary psychotropic medication use. These failures resulted in R10 having been administered an unnecessary antipsychotic medication, resulting in the development of extrapyramidal symptoms/tardive dyskinesia side effects and increased risk of death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's ability to safely self-administer medication, failed to obtain a doctor's order to self-administer medication, and failed to care plan self-administration of medication prior to initiating self-administration of medication. These failures affected one (R59) resident reviewed for self-administration of medication and has the potential to affect all 147 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food that was palatable, attractive and prepared in a manner that conserved nutritive value, flavor and appearance. This failure affected 139 residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy by 1. Failed to ensure male staff properly wear beard nets while in the kitchen. 2. Failed to ensure gloves were removed during food preparation after touching multiple nonfood surfaces and items in the kitchen, and 3. Failed to ensure food in the freezer was properly labeled and dated with a use by date. These failures have the potential to affect all 139 residents receiving food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff don appropriate personal protective equipment (PPE) when providing high contact care to a resident, failed to utilize personal protective equipment per facility policy when coming in contact with soiled linen, and failed to ensure soiled linen was bagged tightly before sending it to the laundry to be cleaned. These failures affected one (R154) resident reviewed for infection control and had the potential to affect all 147 residents at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, functional, and sanitary environment by failing to ensure dryer lint traps were clean and without damage. This failure has the potential to cause a fire and has the potential to affect all 147 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff ordered and administered medications to a newly admitted resident (R156); failed to document the administration of medications immediately following administration for 12 (R6, R25, R52, R61, R87, R106, R115, R120, R126, R131, R139, and R142) residents. These failures affected 13 residents reviewed in a sample of 76 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement individualized fall prevention intervention for a resident identified at risk for falls, failed to prevent falls during provision of ADL (activities of daily living) care, and failed to ensure oxygen tanks were secured in the storage room. These failures affected two (R4 and R8) residents and have the potential to affect all 17 residents in Unit C Wing.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove expired medication from three of four carts reviewed for medication storage. This failure has the potential to affect 53 residents that receive medications from these carts.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that hospice staff received appropriate orientation and demonstrated competency regarding the facility's policies and procedures. These failures affect all 14 (R3, R4, R7, R12, R42, R54, R69, R81, R89, R102, R103, R107, R122, and R138) residents receiving hospice care on the sample list of 76.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that the call light in one shower room on B Wing Unit 2 was functioning properly. This deficiency affected 31 residents, including all 14 residents on B Wing Unit 2 and 17 residents on C Wing Unit 2 of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for one resident (R91) and failed to ensure that the resident's urinary catheter drainage bag was properly covered. These failures affected one (R91) resident in a sample size of 76 residents reviewed for urinary catheters.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to have informed consent prior to initiation of antipsychotic medication, including the risks/benefits, goals of treatment, diagnosis, schedule of administration. This failure affected one resident (R10) in a sample of 72 residents reviewed for consent. R10's face sheet documents in part the following diagnoses: spinal stenosis, unspecified dementia with psychotic disturbance, protein calorie malnutrition, epilepsy, anxiety disorder, severe intellectual disabilities, major depressive disorder, contractures of right upper arm, dysphasia, tremors, dysphagia, and muscle weakness. R10's minimum data set (1/20/2026) documents in part that R10 is rarely/never understood and has severe cognitive impairment for daily decision making. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete assessments and minimum data set items. This failure affected two residents (R10, R138) reviewed for assessment accuracy in a sample of 76 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the resident's care plan to correctly reflect the resident's inability for splint use, and diagnosis related to antipsychotic medication use. This failure affected one resident (R10) reviewed for care plan in a sample of 76 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff ordered and administered medications to a newly admitted resident (R156) and failed to ensure that a witnessed fall was documented in the resident's electronic health record (R8). R156 was admitted to the facility on [DATE] between 1:30 and 2:00PM and did not receive any medications till the morning of 4/21/2026. These failures affected two (R8 and R156) of two residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility guideline and standard of care in utilizing a pressure relieving mattress for one resident (R112) with a history of pressure injuries out of a sample of 76 residents reviewed for pressure injuryFindings:R112 is at risk of pressure injury as evidenced by Minimum Data Set (MDS) Section M dated 4/16/2026 which stated: Is this resident at risk of developing pressure ulcers/injuries? Facility response: Yes. Skin treatment included a pressure reducing device for the bed. On 4/21/2026 at 10:21 AM R112 stated R112 weighed about 203 pounds. V30 (Licensed Practical Nurse/LPN) and surveyor observed pressure relieving mattress setting. V30 stated the mattress was set at between 325 pounds and 350 pounds. On 4/22/2026 at 8:40 AM R112 stated R112's weight was about 203 pounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice. This failure affected one (R88) resident reviewed for respiratory care in the total sample of 76 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check and log the resident's personal refrigerator temperature daily. This failure affected 1 (R62) resident reviewed for personal refrigerator in the total sample of 76 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the daily staffing posting contained the required information at the start of each shift. This failure has the potential to affect all 147 residents that reside within the facility. Facility census (4/20/2026) documents 147 residents reside within the facility. On 4/20/2026 at 9:25 AM, observed the nursing staffing posting across from the front desk. The staffing posting was dated 4/17/2026 and did not contain the name of the facility or census information. Surveyor requested a copy of the staffing posting from V51 (Receptionist). V51 stated, sorry I haven't changed it over for today. It is dated 4/17/2026. It is updated daily, I just haven't changed it over yet. On 4/22/2026 at 4:12 PM, V1 (Administrator) affirmed that the staffing posting is updated daily by the receptionist/front desk staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete the facility accurately consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population, failed to develop and maintain a plan to maximize recruitment and retention of direct care staff, failed to develop contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. These failures have the potential to affect all 147 residents that reside within in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures to ensure residents received showers in accordance with professional standards of practice. This failure applies to one (R4) of four residents reviewed for receiving showers in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their medication administration policy by not administering scheduled pain medication within the hour timeframe as ordered and failed to notify the physician of the missed dose for one (R1) out of three residents reviewed for medication administration in a total sample of four. R1 is a [AGE] year old with the following diagnosis: idiopathic neuropathy, chronic pain syndrome, and venous insufficiency. On 8/5/25 at 3:08PM, R1 said on 7/19/2025 she did not receive the scheduled morning medications at any time during the day shift (7:00 AM - 3:00 PM). R1 said the day shift nurse (V4) did not come into R1's room the whole shift. R1 stated that V4 did not check vitals and did not ask R1 for her pain level. R1 said the CNA (V10) had gotten R1 up from bed around 10:30 AM that morning. [...]

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that 8 of 25 residents (R8, R10, R11, R13, R14, R16, R17, R18) remained free from significant medication errors.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their interventions of ensuring residents were adequately supervised who were identified as high risk for falls when left unattended, failed to modify fall prevention interventions post fall and failed to ensure a resident who is at high risk for falls whom repeatedly exhibited unsafe behaviors when in a reclining chair, was safely positioned in a reclining chair and adequately supervised during care. This failure applies to three of three (R1, R2 and R3) residents reviewed for accidents and resulted in R1 sustaining a facial fracture and intracranial hemorrhage from a fall.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper integrity of the facility roof that resulted in ceiling cracks in two residents' rooms and ensure dust free ventilatory outlets in all residents' rooms throughout the facility. This failure has a potential to affect all 131 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedures for dietary food storage, cleaning, and hand hygiene practices by not ensuring stored foods were free of contaminated substances, not ensuring stored foods were properly labeled, not ensuring coolers and freezers were clean and free of contaminated items, not ensuring food items not intended for resident use were discarded, and not performing hand hygiene after handling contaminated items. This failure applies to all 123 residents receiving food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the pharmacy policy by not storing unopened Insulin in the medication refrigerator and documenting open date labels for three of three (R439, R127, R82) residents reviewed during medication storage and labeling in the sample of 32.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its skin prevention policy and notify one resident's (R1) family regarding a new facility acquired wound timely. This affects one of three (R1) resident reviewed for change in condition notification.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its skin care prevention policy and develop a person-centered care plan with interventions to prevent or reduce the risk of developing skin breakdown. This affects one of three residents (R1) reviewed for care plan development.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its tube feeding policy and check the resident's gastrostomy tube for residual prior to administering medications and bolus feeding. This failure affected one resident (R1) out of three residents reviewed for gastrostomy tubes in a sample of 5.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its enteral tube medication administration policy and administer water in between each medication administered and administer scheduled medications per physician orders for one resident (R1) out of three reviewed for medication administration in a sample of 5.

Inspectors wroteBased on interview and record review the facility failed to follow the plan of care and provide three persons assist with activities of daily living care during bed mobility for a dependent resident. This affected one of three residents (R1) reviewed for avoidable accidents. This failure resulted in R1 falling out of bed when provided one person assist, V1 pushed the linen under R1's body, pushing R1 out of bed. R1 complained of pain, sent to the hospital diagnosed with non-displaced left, 11th rib fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor its call light system and answer call lights within a timely manner for four residents (R2, R3, R4, R6) out of six residents reviewed for call light response times.

Inspectors wroteBased on observation, interview and record review the facility failed to provide treatment as ordered by physician for resident who has swollen bilateral feet. The facility also failed to ensure ongoing assessment, identify, document, and obtain physician order for rashes on entire upper back, lateral, medial upper arm, and open wound on upper back This failure affects two (R34 and R90) of three residents in the sample of 22 reviewed for Quality of care.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to utilize two persons assist for bed mobility (R1), failed to utilize a gait belt to assist with transfers (R18), failed to ensure wheelchair leg supports were in place during transport (R9), and failed implement an effective plan to prevent or reduce the risk of falling with injury for a resident identified to be at risk for falling out of bed (R13). This affected (R1, R9, 18, and R13) reviewed for safety during care and fall prevention interventions on the sample list of 21. This failure resulted in R1 rolling off the bed onto the floor while staff was providing care. R1 sustained an impacted/displaced fracture to the left upper arm with abrasion to the left knee and toe. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pest management program by not maintaining a clean kitchen dry storage area which resulted in live ants and mice droppings being observed which has the potential to affect all 104 residents that participate in dining services.

Inspectors wroteBased on interview and record review, the facility failed to inform the primary care physician of the change of condition for one of one resident (R21) reviewed for change of condition in a sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident who was identified as a maximum assist with activities of daily living prior to discharge and recommended 24-hour care was safely discharged back to his home. This affected one of three residents (R6) reviewed for sufficient preparation for transfer on the sample list of 21. This failure resulted in R6 being discharged home alone without 24 hour care to assist with incontinence care and lead to R6 being sent back to local emergency room with stage 1 pressure sore to buttocks six days after discharge.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan after a change of condition for one of one resident (R21) reviewed for care plan in a sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care at least every two hours, and failed to ensure a shower or bath was provided at least two times a week. This affected two of three residents (R7, R10) reviewed activities of daily living care on the sample list of 21. This failure resulted in R7 being left and saturated in urine, and R10 receiving 1 staff provided bath in approximately 15 days. Findings Include: 1) R7 has the diagnosis of Cerebral Infarction. Minimal data set section C (cognitive patterns) dated 9/21/23 documents a score of eight which indicates moderate impairment. Section G (functional status) documents: R7 requires extensive assistance with one person physical assist with toilet use. Section H (bladder and bowel) documents: [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor the resident after a fall for one of one resident (R21) reviewed for accidents in a sample of 10.