Aliya of Crestwood

In the surveyor’s words

From the most serious findings on record at Aliya of Crestwood, in the surveyor’s own words.

• Actual harm, isolatedF691Jun 30, 2026

  Based 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.Findings include: R1's facility sheet shows diagnoses of colostomy status. […]

• Actual harm, isolatedF684Jun 2, 2026

  Based 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. […]

• Actual harm, isolatedF605Apr 23, 2026

  Based 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. […]

• Actual harm, isolatedF684Feb 20, 2026

  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. […]

• Actual harm, isolatedF689Apr 17, 2025

  Based 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. Findings include: 1. […]