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Complaint Investigation

Aliya Of Glenwood

December 31, 2025 · Glenwood, IL · 19330 South Cottage Grove
Citations 1
CMS Rating 1/5
Beds 184
Provider ID 145758
Healthcare Facility
Aliya Of Glenwood
Glenwood, IL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

ALIYA OF GLENWOOD in GLENWOOD, IL — inspection on December 31, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0684
Quality of Life and Care Deficiencies

with the doctors. A lot of the surgeons don't want the dressing removed.

Upon review of R1's TAR

(10/06/25). I'm pretty new here. V5 affirmed that dressing care is dependent on physician orders and

indicate the treatment was completed. On 12/30/25 at 12:42pm, upon review of R1, R2, R3, and R4's TARs (Treatment Administration Record) with V2 (Director of Nursing/DON), V2 said, I cannot locate any documentation showing the dressings were changed.

The number one rule is that if it's not signed, it's not done. V2 affirmed that the nurses should be signing the TARs after completion of changing resident's dressings. On 12/30/25 at 1:55pm, V10 (Infection Preventionist) said, IP said, PICC (peripherally inserted central catheter) line dressing are changed every 7 days.

The purpose is to monitor the site, prevent any further infections.

The purpose for changing wound dressing as ordered is to prevent further infection, prevent further wound damaging and prevent worsening of the wounds.

Record review of facility policy titled Skin Management: Monitoring of Wounds and Documentation, dated 5/2025, documents, in part, It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility.

With each dressing change or at least weekly, an evaluation should be documented. At a minimum, documentation should include the date observed and: Location and staging; Size, depth, and the presence of any undermining or tunneling; Exudate, if present; Pain; Wound bed description; and Description of wound edges.

Record review of facility policy titled Physician Orders, dated 5/01/25, documents, in part, Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order.

The order is recorded on the physician order sheet in PCC (PointClickCare) and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR).

The following steps are initiated to complete documentation: a.

Clarify the order; b.

Enter the orders with administration schedule in PCC and transit to pharmacy; c. If order is replacing a previous order, d/c previous order in PCC.Record review of facility policy titled, Infection Control Program- General, dated 2/2025, (Name of Facility) is committed to ensuring that all appropriate infection and control measures are in place as determined by State and Federal Regulations as well as CDC (Center for Disease Control) recommendations and guidance.

The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility.

Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Your facility must provide equal access to quality care regardless of diagnosis.

You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually.

Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Your facility must be safe, clean, comfortable, and homelike.

You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do.

This plan must include your personal and cultural choices.

Your facility must make reasonable arrangements to meet your needs and choices.

You should receive the services and/or items included in the plan of care.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENWOOD, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALIYA OF GLENWOOD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.