Aliya of Glenwood: Heart Medication Missing 4 Days - IL
The patient, diagnosed with both heart failure and hypertension, missed doses of Toprol XL from August 8 through August 11. Nurse V4, who worked those shifts, marked the medication as "not available" in electronic records each day.
When questioned by inspectors, V4 admitted she called the pharmacy for delivery but never checked the facility's convenience box. "She should have retrieved the medication from the convenience box and did not," the nurse told investigators.
The Director of Nursing was blunt about expectations: "I expect all medications to be given to the resident's as ordered and retrieved from the convenience box if available."
A second incident involved a patient with severe burns to both lower legs who was denied pain medication during a night shift. The resident told inspectors that on August 17 around 12:30 a.m., she informed a nursing assistant that she needed pain medication. Her pain level was 8 out of 10.
Two hours later, the night nurse arrived at her room with bad news. The nurse "said she did not have any pain medication available and that it would be delivered in the morning," the resident recounted.
Night nurse V8 confirmed the sequence of events. "I did check for pain medication for R3 and she did not have any. I followed up with the pharmacy and the pharmacy indicated that the medication would be delivered in the early morning."
The nurse offered an alternative medication, but the resident declined. Like her colleague on the day shift, V8 acknowledged the obvious failure: "I should have gotten it out of the convenience box, I don't know why I didn't."
The patient requiring pain medication had extensive medical needs. Records show diagnoses of low back pain, blood clots, and post-traumatic stress syndrome alongside burns covering both lower legs. Her wound care orders required cleaning and dressing changes every shift, with specific instructions to "cleanse with wound cleanser and gently pat dry, cover open areas with xeroform and abdominal dressing pads."
Her prescribed pain medication was oxycodone-acetaminophen, ordered as one tablet every four hours as needed for pain and discomfort.
Both medication failures occurred despite clear facility policies. The nursing home's medication administration policy, reviewed in January 2024, states that when "medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box."
The policy emphasizes that "all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms."
Federal inspectors reviewed medication administration for five residents and found these failures in two of the three cases they examined in detail. Both incidents involved nurses who acknowledged they knew about the convenience box system but failed to use it.
The heart failure patient's care plan specifically identified potential for "altered cardiac function related to diagnosis of hypertension and heart failure" with an intervention to "administer medication as ordered." Missing four days of beta blocker medication directly contradicted this documented care approach.
For the burn patient, her care plan from August 7 focused on "pain and discomfort low back pain, wounds" with intervention to "administer pain meds and treatments as ordered." The overnight medication denial left her suffering with level 8 pain until morning delivery.
The convenience box system appears designed exactly for these situations. Both nurses understood the protocol existed and admitted they should have used it. Neither offered explanations for why they chose to leave patients without prescribed medications rather than walk to the backup supply.
The Director of Nursing's repeated emphasis on expectations suggests these weren't isolated oversights but part of a pattern requiring management attention. Her identical phrasing in both cases indicated ongoing concerns about medication availability.
The inspection occurred August 22, following a complaint that prompted federal review. Inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents.
The heart patient continued missing critical cardiac medication while nurses made phone calls instead of checking supplies steps away. The burn patient endured hours of severe pain while staff offered alternatives she didn't want rather than retrieving what she was prescribed.
Both residents had complex medical conditions requiring consistent medication management. Both were failed by nurses who knew better but didn't act.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aliya of Glenwood from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALIYA OF GLENWOOD in GLENWOOD, IL was cited for violations during a health inspection on August 22, 2025.
The patient, diagnosed with both heart failure and hypertension, missed doses of Toprol XL from August 8 through August 11.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.