Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aliya Of Homewood during CMS and state inspections, most recent first.
The facility failed to follow its fall-prevention policy, resulting in multiple high-risk residents experiencing repeated falls and injuries. One resident with severe cognitive impairment and hemiplegia, assessed as needing maximal assistance and unable to transfer safely, fell twice from bed, including a fall causing a head laceration requiring staples, while care-planned interventions were limited to bed equipment and therapy staff were unaware of the recent falls and left the resident in a wheelchair with only line-of-sight supervision. Another resident with seizures, poor coordination, and a history of falls had multiple falls at the nurse’s station and in the room, including a facial laceration, while the post-fall risk assessment omitted prior falls, and staff could not clearly describe transfer methods or consistently mention care-planned frequent rounding. A third resident with a non–weight-bearing pelvic fracture and high fall risk fell while trying to reach the bathroom after admission; the non–weight-bearing order and fracture were not incorporated into the care plan, and staff were unsure of the resident’s weight-bearing status and fall precautions. A fourth resident with multiple sclerosis and legal blindness had a care-planned floor mat that was folded and positioned away from the bed due to an over-bed table, leaving the resident unprotected if rolling out of bed, which staff acknowledged on observation.
A resident’s post-fall risk assessment was completed inaccurately and left incomplete, with a key section on falls, accidents, and fractures left blank. The item regarding a history of falls, which should have included the current fall, was not selected, resulting in a documented fall risk score of 7 instead of the correct score of 17. During an interview, the DON acknowledged that omitting this section altered the score and that the resident should have been classified as high risk for falls. This failure occurred despite a facility policy requiring comprehensive fall risk evaluations on admission, readmission, quarterly, with significant change, and after each fall.
A resident admitted with a history of falls and a right pelvic fracture had physician orders for non-weight bearing to the right leg, but the baseline care plan developed within 48 hours did not include the pelvic fracture or non-weight bearing status. Instead, the resident was care planned only as high risk for falls due to reduced mobility and poor safety awareness, with general interventions such as low bed position, call light within reach, and staff assistance as needed. During surveyor interview, the DON confirmed that the non-weight bearing and specific transfer requirements were omitted from the baseline care plan, despite hospital records with these orders being available prior to admission.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident with a history of stroke, left-sided weakness, and moderate cognitive impairment was not adequately supervised during a transfer when a CNA turned to retrieve a wheelchair, allowing the resident to reach for an item on the floor and fall, resulting in a head laceration and subdural hematoma. The resident's fall risk was underestimated due to errors in assessment, and known behaviors that increased fall risk were not sufficiently addressed during care.
A resident on Enhanced Barrier Precaution was prescribed Metronidazole without a documented stop date, contrary to the facility's Antibiotic Stewardship Program. The Infection Control Nurse and DON acknowledged the oversight, which violated the policy requiring documentation of dose, duration, route, and indication for all antibiotics.
A resident was prescribed Metronidazole without proper documentation and monitoring as required by the facility's Antibiotic Stewardship Program. The Infection Preventionist could not locate the infection assessment evaluation record, and the Director of Nursing acknowledged the need for ongoing monitoring. The resident had diagnoses including sepsis and a periprosthetic fracture, with an active order for Metronidazole starting in late September.
A facility failed to follow physician orders for a urinalysis, leading to a resident's hospitalization with a UTI and sepsis. Additionally, the facility did not conduct a comprehensive assessment for a resident in pain, resulting in a delayed diagnosis of a severe hip fracture. These deficiencies highlight the facility's failure to adhere to proper procedures for assessing and responding to changes in residents' conditions.
Two residents with severe cognitive impairments experienced multiple falls due to the facility's failure to implement effective individualized fall interventions. One resident sustained serious injuries requiring hospitalization, while another was left unsupervised for 13 minutes after a fall. The facility's interventions, such as floor mats and perimeter pillows, were inadequate in preventing falls, and immediate supervision and assessment were lacking.
A resident experienced significant pain in the left leg, later identified as an impacted transcervical fracture. Despite observations by a CNA and a nurse, the facility failed to notify the physician or emergency contact on the day of the incident, resulting in a delay in treatment orders for over 24 hours.
A facility failed to issue a refund of $19,950.00 within 30 days after a resident's death, as required by their internal policy. The delay was due to the absence of the corporate staff member responsible for processing refunds. This failure to adhere to the refund process policy resulted in a deficiency related to the misappropriation of resident funds.
Failure to Implement and Communicate Effective Fall-Prevention Measures for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall-prevention interventions for multiple residents at high risk for falls. The facility’s own fall incident log showed 42 falls in a two‑month period. For one resident with anxiety, restlessness, agitation, hemiplegia, and hemiparesis, functional assessments documented a need for substantial/maximal assistance with bed mobility and that transfers were not attempted due to medical or safety concerns, yet this resident experienced two falls within days. After the first fall, the resident reported trying to go to the bathroom, and the incident report identified confusion, gait imbalance, and incontinence as predisposing factors, with a winged mattress added as an intervention. After the second fall, the resident was found on the floor outside the floor mats with a head laceration requiring staples, and staff documented that the resident was always attempting to get out of bed. Despite this, the care plan only reflected bed‑related interventions (wing mattress, ultra‑low bed, floor mats) and did not include supervision details, and therapy staff were unaware of the recent falls and left the resident in a specialty wheelchair in the therapy gym with only line‑of‑sight supervision while the therapist’s back was turned. Another resident with seizures, lack of coordination, muscle wasting/atrophy, and a history of falling had multiple falls documented at the nurse’s station and in the room. The resident’s post‑fall risk assessment failed to include a history of falls and/or fracture in the past six months, which would have increased the fall risk score. Incident reports described the resident having a seizure and falling from a wheelchair at the nurse’s station with a head injury, later documentation at the hospital describing an abrasion and hematoma, and subsequent falls where the resident was found on the floor after attempting to go to another room, including a fall at the nurse’s station resulting in a laceration to the eyelid. The care plan identified the resident as high risk for falls with interventions such as staff assistance as needed and frequent rounding, but nursing staff interviewed only cited low bed, floor mats, soft helmet, and call light within reach, and did not mention frequent rounding. One LPN was not sure how the resident was to be transferred from bed to wheelchair, and another RN described the resident falling face down from a chair at the nurse’s station and sustaining a laceration to the eye, while documentation of the side of injury was inconsistent between facility and hospital records. A third resident with Parkinson’s disease, muscle wasting/atrophy, cognitive communication deficit, diabetes, chronic kidney disease, hypertension, benign prostatic hyperplasia, history of falling, and a recent right pelvic fracture with a non‑weight‑bearing order to the right leg was admitted after a fall at home. Functional assessments showed impairment in range of motion and a need for partial/moderate assistance with toileting and substantial/maximal assistance with transfers, with walking not attempted due to safety concerns. The fall risk assessment scored the resident as high risk, but the care plan did not include the non‑weight‑bearing status or the fractured pubis as a factor, and interventions were limited to low bed, call light and frequently used items within reach, and staff assistance as needed. The resident fell while trying to get to the bathroom, was found on the floor with a knot and redness on the head, and was sent to the hospital, where he was admitted for a fall and non‑acute pelvic fracture. The DON later confirmed that the non‑weight‑bearing order was not on the care plan, and a nurse reported that CNAs were transferring the resident with one‑person assist and that she was unsure of the resident’s weight‑bearing status or specific fall precautions. A fourth resident with legal blindness, multiple sclerosis, weakness, restlessness, and agitation had a care plan identifying high fall risk with floor mats as an intervention while in bed. The resident’s functional assessment showed a need for substantial/maximal assistance with rolling and that transfers were not attempted due to medical or safety concerns. During observation, the floor mat intended to protect the resident was folded and angled away from the bed, with an over‑bed table stored under the bed preventing proper placement of the mat. An LPN acknowledged that the mat should be bedside and that, in its current position, if the resident rolled out of bed between the beds, the resident would land on the floor. The ADON had to enter the room, move the over‑bed table, and reposition the mat correctly. Across these residents, staff interviews revealed lack of awareness of recent falls, uncertainty about transfer requirements and weight‑bearing status, incomplete or inaccurate fall risk assessments, and failure to implement or consistently apply care‑planned fall‑prevention interventions, including supervision and environmental safeguards, contrary to the facility’s fall prevention and management policy that requires identification of residents at risk, completion of fall risk evaluations, and modification of care plans after each fall.
Incomplete and Inaccurate Post-Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy and to ensure accurate and complete fall risk assessments for a resident reviewed for falls. For one resident (R4), a post-fall risk assessment dated 1/2/26 was incomplete because section G, which addresses falls, accidents, and fractures, was left blank. Specifically, the item asking whether there was a history of falls and/or fracture in the past six months, including the current fall incident, was not selected, even though the assessment was conducted after a fall and should have included the current incident. As a result, the resident’s fall risk score was documented as 7 (at risk) instead of 17 (high risk), as later acknowledged by the DON when interviewed by the surveyor. The facility’s fall prevention and management policy, reviewed in March 2026, requires that a fall risk evaluation be completed on admission, readmission, quarterly, with significant change, and after each fall, but this post-fall assessment was not accurately completed in accordance with that policy. The surveyor’s interview with the DON confirmed that leaving section G unchecked would alter the calculated score and that the correct score, if accurately assessed, should have been 17, which would classify the resident as high risk for falls. This demonstrates that the resident’s post-fall risk assessment was both incomplete and inaccurate, directly contradicting the facility’s stated procedures for identifying and evaluating residents at risk for falls.
Failure to Include Non-Weight Bearing Status in Baseline Fall Care Plan
Penalty
Summary
The facility failed to follow its baseline care plan policy and did not ensure that required diagnoses and interventions related to fall risk were included in a newly admitted resident’s baseline care plan. The resident was admitted with diagnoses including a history of falling and a right pelvic fracture, with physician orders specifying non-weight bearing to the right leg. Despite these documented conditions and orders, the baseline care plan developed within the first days after admission identified the resident as high risk for falls only in relation to reduced mobility and poor safety awareness, and did not include the right pelvic fracture or the non-weight bearing status of the right leg. The baseline care plan interventions focused on general fall prevention measures such as keeping the bed in the lowest position, placing frequently used items and the call light within reach, and having staff assist as needed. These interventions did not address the specific non-weight bearing and transfer requirements associated with the resident’s right pelvic fracture. During an interview, the DON reviewed the baseline care plan and confirmed that the non-weight bearing right leg and pelvic fracture were not included, even though the hospital records with the non-weight bearing order had been received prior to admission. This omission occurred despite the facility’s written policy requiring that the baseline care plan, developed within 48 hours of admission, include necessary information such as fall risk to properly care for the resident.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subdural hemorrhage, aphasia, left-sided hemiplegia, glaucoma, and cognitive communication deficit was not adequately supervised during a transfer. The certified nursing assistant (CNA) was providing morning care and had positioned the resident on the side of the bed in preparation for transfer. While the CNA turned to retrieve the wheelchair, the resident reached for an item on the floor, lost balance, and fell forward, striking their head on the nightstand and then the floor. The incident was witnessed by the CNA, who reported being one to two feet away and momentarily distracted while setting up the wheelchair in front of the resident. The resident sustained a laceration to the left side of the forehead with moderate bleeding and was subsequently hospitalized. Medical evaluation revealed a small subdural hematoma and a small hemorrhagic contusion to the left frontal lobe. The resident was admitted for monitoring and further evaluation, including imaging studies that confirmed the injuries. The resident's care records indicated a history of left-sided weakness and moderate cognitive impairment, requiring substantial assistance with bed mobility and transfers. The care plan and therapy notes documented the resident as a fall risk due to impaired mobility, cognitive deficits, and a history of stroke. Review of the facility's fall risk assessments revealed inconsistencies and errors in scoring, with one assessment incorrectly indicating the resident was not at high risk for falls. The resident's care plan prior to the incident included interventions for fall prevention, but the supervision provided during the transfer was insufficient to prevent the fall. Staff interviews confirmed that the resident had a known behavior of reaching for objects, which was not adequately addressed during the transfer process.
Deficiency in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to ensure that a resident's antibiotic regimen was properly documented and managed according to their Antibiotic Stewardship Program. A resident, identified as R103, was on Enhanced Barrier Precaution and reported taking an antibiotic for an infection since their admission in September 2024. However, the prescribed antibiotic, Metronidazole, lacked a documented stop date, which is a requirement under the facility's policy. The Infection Control Nurse, V4, and the Director of Nursing, V2, both acknowledged that the antibiotic should have included a start and stop date, along with an indication for use, and that the doctor should have been informed if the duration was not indicated. The Licensed Practical Nurse, V14, who regularly works on the unit where R103 resides, confirmed that the physician's order for Metronidazole did not include a stop date. The facility's policy mandates that the dose, duration, route, and indication of every antibiotic prescription must be documented in the medical record for every resident. This oversight in documentation and communication regarding the antibiotic regimen for R103 represents a deficiency in the facility's adherence to its own Antibiotic Stewardship guidelines, which are aligned with CDC and CMS standards.
Failure in Antibiotic Monitoring for a Resident
Penalty
Summary
The facility failed to implement ongoing monitoring of antibiotics as part of its Antibiotic Stewardship Program, affecting one resident in a sample of 23. During an interview, the Infection Preventionist (V4) stated that she reviews antibiotic prescriptions weekly and conducts an infection assessment evaluation before starting antibiotic use. However, she was unable to locate the infection assessment evaluation record for a resident (R103) who was prescribed Metronidazole 500mg every 12 hours for a bacterial infection without a stop date. This indicates a lapse in the documentation and monitoring process required by the facility's policy. The Director of Nursing (V2) expressed that the expectation for the antibiotic stewardship program is to ensure ongoing monitoring of antibiotics. The resident in question was admitted with diagnoses including sepsis and a periprosthetic fracture, and had an active physician order for Metronidazole starting on 9/26/24. The facility's policy, reviewed in February 2024, mandates that the dose, duration, route, and indication of every antibiotic prescription be documented in the medical record. Additionally, the policy requires the use of specific criteria for initiating antibiotic usage, which was not adhered to in this case.
Failure to Follow Physician Orders and Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to follow physician orders for a resident who was incontinent of urine and exhibited new onset lethargy. The physician had ordered a STAT chest x-ray, CBC, CMP, and urinalysis with culture and sensitivity. However, the facility did not notify the lab for urine collection, nor did they obtain a urine specimen for the resident. The nurse consultant and nurse practitioner confirmed that the staff should have collected the specimen or obtained an order for a straight catheter if necessary. This oversight resulted in the resident being hospitalized with a diagnosis of urinary tract infection and sepsis. Another deficiency involved a resident who was observed with his left leg/knee contorted under his wheelchair, exhibiting facial grimacing and yelling out in pain. Despite these signs, the nurse did not conduct a comprehensive body assessment or notify the medical doctor of the resident's change in condition. The resident was left in pain for twenty hours before an x-ray was ordered, which revealed a new acute transcervical left femoral neck fracture. The medical doctor stated that the nurse should have laid the resident down and completed a full body exam, including range of motion of the extremities, after observing the resident's pain. The report highlights the facility's failure to adhere to proper procedures for assessing and responding to changes in residents' conditions. In both cases, the lack of timely and appropriate action led to significant health issues for the residents, including hospitalization and a severe fracture. The facility's staff did not follow through with necessary medical assessments and communication with physicians, resulting in delayed treatment and care for the affected residents.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective individualized fall interventions for two residents, resulting in multiple falls. One resident, diagnosed with Alzheimer's Disease and dementia, was identified as a high fall risk. Despite this, the facility did not implement individualized preventive fall interventions after the resident's first fall. The resident sustained a second unwitnessed fall from bed, resulting in a comminuted displaced fracture of the bilateral nasal bones and a lip laceration, requiring hospitalization. The interventions in place, such as floor mats, were not effective in preventing falls, as confirmed by the restorative nurse. Another resident, under hospice care with severe cognitive impairment, experienced two fall incidents. The first fall led to the addition of perimeter pillows as an intervention. However, the second fall occurred despite the resident being rounded on 10 minutes prior. The resident was found on the floor by a family member and left unsupervised for 13 minutes before staff assistance was provided. The facility's policy requires immediate assessment and supervision of residents after a fall, which was not adhered to in this case. The facility's fall prevention and management policy emphasizes the need for individualized interventions based on root cause analysis after each fall. However, the interventions implemented for both residents were not sufficiently individualized or effective in preventing further falls. The lack of immediate supervision and assessment after falls further contributed to the deficiency in care provided to these residents.
Failure to Notify Physician of Resident's Acute Change in Condition
Penalty
Summary
The facility failed to notify a physician of an acute change in condition for a resident, as required by their change in condition policy. This failure affected a resident who was experiencing significant pain in the left leg, which was later identified as an impacted transcervical fracture. The resident was initially observed by a CNA and a nurse, who noted the resident's grimacing and resistance to moving the left leg. Despite these observations, the nurse did not notify the resident's physician or emergency contact on the day of the incident. The resident's condition was not communicated to the physician until after the resident was sent to the hospital the following day. The delay in notification resulted in a delay in treatment orders for over 24 hours. The facility's policy requires notifying the resident's physician and responsible party of any significant change in condition, which was not adhered to in this case. The resident's medical record lacked documentation of any notification to the doctor or family on the day of the incident.
Delayed Refund for Deceased Resident
Penalty
Summary
The facility failed to adhere to its internal refund process policy by not issuing a refund of $19,950.00 within 30 days following the death of a resident. The resident, who was under hospice private pay, was admitted to the facility and later expired there. According to the facility's policy, a refund should be processed within 30 days from the date of death or discharge. However, the refund was delayed due to the absence of the corporate staff member responsible for processing refunds, who had been let go. This delay affected the timely issuance of the refund check to the resident's family. The facility's internal refund process policy mandates that credit balances due to residents should be refunded within 30 days from the date of death or discharge. Additionally, the facility's Abuse Policy and Prevention Program emphasizes the residents' right to be free from misappropriation of property, which includes the wrongful use of a resident's belongings or money. Despite these policies, the facility did not meet the state compliance requirement, resulting in a deficiency related to the misappropriation of resident funds.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Homewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ryze At Homewood | 1.6 mi | ★★★★★ | 13 | 1 |
| Elevate Care South Holland | 2.7 mi | ★★★★★ | 12 | 0 |
| Prairie Oasis | 2.9 mi | ★★★★★ | 33 | 1 |
| Pine Crest Health Care | 2.9 mi | ★★★★★ | 21 | 0 |
| Heather Health Care Center | 2.9 mi | ★★★★★ | 19 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.