Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 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.
Failure to report poor intake and significant weight loss: A resident had repeated meal refusals and very low PO intake over several months, with coughing noted during meals while positioned at 45 degrees. The attending MD and RD stated they were not notified of the resident’s poor appetite or weight loss, and the record showed a drop from 150 lbs to 130.5 lbs without documentation that the loss was medically unavoidable.
Two residents dependent on enteral feedings did not receive nutrition as ordered, and both lost weight while pump observations showed they were often not connected to their feeds during the day. The RD stated both residents were not receiving adequate nutrition, and the DON stated nurses were not competencied on the feeding pump; the facility could not document training for most licensed nurses, and one nurse could not explain how to verify feeding delivery or pump settings.
The facility failed to follow its call light response policy and ensure call light cords were within reach for 4 residents. One resident in a wheelchair and three residents in bed or a reclining chair were observed with call light cords on the floor, on a nightstand at the head of the bed, or dangling behind the nightstand, all not within reach. An RN stated the call light cord should definitely be within the resident's reach, and the facility policy states the call light must always be within easy reach.
Failure to provide timely incontinence care, hygiene, and skin care affected multiple residents who were dependent on staff for ADLs. A cognitively intact resident, two residents with cognitive impairment, and another resident were found wet or saturated with urine, with soiled bedding and odor noted, while staff delayed care or did not complete timely rounds. Another resident was observed with severe dry, flaky feet and socks filled with skin flakes, despite the resident requesting foot washing and moisturizing and staff stating foot care should be provided on shower days and as needed.
Opened eye drops and insulin products were found undated on medication carts during a med cart audit. An RN and other nursing staff acknowledged the medications should have been dated when opened, including eye drops for residents with glaucoma and prednisolone orders, and insulin for residents with diabetes. The facility policy cited requires medications and biologicals to be stored safely and in line with manufacturer or supplier recommendations.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility failed to obtain informed consent before starting psychotropic medications for two residents. One resident with schizophrenia, seizures, and traumatic subdural hemorrhage received Seroquel, duloxetine, and mirtazapine before consent was documented, and another resident with bipolar disorder and depression had no consent in the record for Depakote or a sertraline dose increase. The DON confirmed consent should be obtained prior to starting these medications.
Failure to complete required psychotropic monitoring and individualized interventions. Two residents receiving psychotropic meds had missing or incomplete psychotropic med assessments, missing or overdue AIMS assessments, and no documented individualized nonpharmacological interventions in their care plans. The DON confirmed the missing documentation during the survey.
A resident with a facility-acquired stage 3 coccyx pressure injury, hemiplegia, and DM did not receive ordered wound care or regular turning/repositioning. Staff observed the resident lying supine for an extended period without being turned, and the sacral dressing was not in place when checked. The CNA said she last turned the resident earlier in the morning and did not notify the nurse, while the wound care nurse and DON stated staff were expected to report missing dressings and provide turns every 2 hours or as needed.
Inadequate competency for enteral feeding pump use. A nurse could not explain key pump functions, shift-to-shift communication, or how to verify feeding totals, while the DON stated nurses were not competencied on the pump. Three residents receiving enteral nutrition were observed not connected to their pumps at times, and the RD reviewed pump totals showing two residents had not received ordered feeding and water flush amounts. The facility could not produce documentation showing all nurses were trained or competent with the pump.
Failure to follow EBP procedures occurred when staff entered resident rooms and provided direct care without the required gown and glove PPE. A CNA entered one resident's EBP room without a gown while handling linens, and two restorative aides entered another resident's EBP room without appropriate PPE while using a mechanical lift for a weight. The facility also did not place a resident with a G-tube and enteral feeding pump in EBP, as there was no EBP signage or PPE bin outside the room.
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 Report Poor Intake and Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and registered dietitian of a resident’s poor appetite and decreased oral intake, and failed to implement timely interventions to prevent further decline. R9 had repeated meal refusals and very low intake documented over multiple months, including numerous meals consumed at 0-25% or 26-50% and several refusals. The attending physician stated he was not made aware of the resident’s poor appetite or weight loss, and the registered dietitian stated she was not informed of the frequency of low intake and would have made supplement recommendations if staff had notified her. R9’s weight records showed a decline from 150 pounds on 12/3/25 to 130.5 pounds on 2/19/26, with survey observation confirming the weight at 130.5 pounds. During meal observations, R9 was seen eating very little and coughing while eating, with the head of bed at 45 degrees during meals. The speech therapist stated there is a direct relationship between coughing and not being at 90 degrees, and recommended upright positioning, 1:1 feeding assistance, alternating liquids and solids, and soft and bite-sized food. The facility’s weight change policy required monitoring significant weight changes and notifying the dietitian, physician, and resident representative, but the record contained no documentation that the physician was notified each time R9 consumed 0-25% or refused meals, and no documentation that the weight loss was medically unavoidable.
Enteral Feeding Not Delivered as Ordered and Staff Competency Not Documented
Penalty
Summary
The facility failed to ensure that two residents who were dependent on enteral feedings received nutrition as ordered. One resident had a significant weight loss of 14.1% between July 2025 and February 2026, and another resident lost 4.4% within eight weeks of admission. Observations showed both residents were frequently not connected to their enteral feeding pumps during the day, including while one resident was self-propelling in the halls and attending activities and while the other was in bed, in a wheelchair at the nurses’ station, or with family. Pump containers showed that each resident received less feeding than ordered over 24- and 48-hour periods, and the RD stated that both residents were not receiving adequate nutrition. The RD also stated that enteral feedings were ordered to run over 20 hours daily to ensure the residents received adequate nutrition, and that the total volume was based on caloric needs. The facility also failed to ensure staff demonstrated competency in the administration and management of enteral nutrition. The DON stated nurses received an in-service on the enteral feeding pump one year earlier, but they were not competencied on the pump, and nurses hired after 1/27/25 were supposed to receive 1:1 orientation training. The facility could provide documentation for only 6 of 47 licensed nurses who attended the 1/27/25 in-service and could not provide documentation that the 21 nurses hired after that date received orientation training or that the remaining nurses received education on the feeding pump. During interview, a nurse could not explain how feeding delivery was communicated between shifts, how to determine when the resident had received the total daily amount, or how to check pump settings and amount fed. The facility’s tube feeding policy stated that the provider should be notified if the tube feeding amount was not infused as ordered, the pump should be cleared at the end of each shift, and tube feeding delivered should be documented.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to follow its call light response policy and ensure call light cords were within reach for 4 residents reviewed for call light accessibility. R60 was observed sitting in a wheelchair across from the bed, with the call light cord on the floor under the bed and not within reach. R126 was observed lying in bed with the call light cord on the floor under the bed and not within reach. R91 was observed sitting in a reclining chair next to the foot of the bed, with the call light cord on the nightstand at the head of the bed and not within reach. R114 was observed lying in bed with the call light cord dangling behind the nightstand and not within reach. An RN stated that the resident's call light cord should definitely be within the resident's reach. The facility's policy dated 5/1/25 states to ensure the call light is always within the resident's reach and, when the resident is in bed, to provide the call light within easy reach of the resident.
Failure to Provide Timely Incontinence, Hygiene, and Skin Care
Penalty
Summary
The facility failed to ensure timely incontinence care, hygiene, and skin care for multiple residents who were dependent on staff for these services. For R126, the CNA stated the resident had last been changed at 6:30 AM, and later the resident stated he needed a brief change and did not know where his call light cord was. The call light cord was observed under the bed, and when the nurse placed it within reach, the resident again stated he needed to be changed. When the CNA returned, R126’s brief was saturated with urine and the bed linen was wet with a brown discoloration outlining the wet area. R126’s MDS showed he was cognitively intact, dependent on staff for incontinence care, and his care plan directed staff to keep him clean and dry and provide incontinence care at routine timely intervals. R9 was observed lying in bed with a strong foul odor near the bed. The CNA entered the room briefly, moved the bedside table, and left. The lunch tray was later delivered, and the CNA was observed encouraging the resident to eat, but the resident was not provided incontinence care until later in the afternoon, when the brief was found saturated. R9’s care plan identified bowel and bladder incontinence related to impaired mobility and cognition and directed staff to provide incontinence care as needed and apply skin moisturizers/barrier creams as needed. R89 was also observed during wound care with a brief saturated with urine. R89’s MDS showed moderate cognitive impairment and dependence on staff for incontinence care. R44 was observed in bed with an odor of urine and stated she was wet and needed to be changed. The CNA said the last check had been at 7:30 AM and that she had not checked on R44 because she was busy getting other residents up, and the resident was observed with no brief on and soiled bedding. R11 was observed with severe flaky skin on both feet, with dry skin flakes inside the socks, and the resident stated she wanted her feet washed and moisturized. Staff stated aides should be washing and moisturizing the resident’s feet on shower days and as needed, and the wound care nurse stated the feet had not become that dry since the last skin check and that she needed to address foot care with staff. R11’s care plan directed staff to assist with bathing, daily hygiene, grooming, dressing, oral care, and eating as needed, and facility policies stated foot care is provided to promote cleanliness, prevent infection, control odor, comfort, and monitoring for skin breakdown.
Opened Medications Found Undated on Medication Carts
Penalty
Summary
The facility failed to ensure that medications were labeled and stored in accordance with facility policy and accepted standards of practice. During a medication cart audit, surveyors observed opened medications that were not dated upon opening, including Latanoprost eye drops for a resident with glaucoma, prednisolone eye drops for a resident with an order for prednisolone acetate ophthalmic solution, and insulin products for two residents with diabetes mellitus. Staff acknowledged that the medications should have been dated when opened and stated that dating is used to track the expiration date and prevent administration of expired medication. The observations involved four residents: one with glaucoma receiving Xalatan ophthalmic solution, one with diabetes mellitus and hyperglycemia receiving insulin glargine, and two residents with type 2 diabetes mellitus receiving insulin lispro and insulin glargine. The report also cites the facility’s Medication Storage policy, which states that medications and biologicals are to be stored safely, securely, and properly following manufacturer or supplier recommendations. The deficiency was identified through observation, interview, and record review of the medication carts.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications before administration for two residents reviewed for resident rights. One resident was admitted with diagnoses including schizophrenia, seizures, and traumatic subdural hemorrhage, and the physician order sheet showed Seroquel, duloxetine, and mirtazapine with order and start dates before the consent documentation was completed. The consent form for these medications documented verbal consent from a family member and a facility representative signature, but the signing date of the assessment was later than the medication start dates. The pharmacy medication review also stated there was no informed consent for duloxetine, mirtazapine, and Seroquel. A second resident was admitted with diagnoses of bipolar disorder and depression and had orders for Depakote and sertraline, including a sertraline dose increase history. During interview, the DON stated consents are obtained upon admission or with new orders or dose increases, and that consent should be obtained prior to starting the medications. The DON later confirmed there were no consents in the medical record for the resident's Depakote or sertraline increase. The facility policy stated that when a new psychotropic medication order is obtained, the resident or representative must be informed of the risks and benefits and informed consent must be obtained.
Failure to complete required psychotropic monitoring and individualized interventions
Penalty
Summary
The facility failed to follow its Psychotropic Medication Program for two residents by not completing psychotropic medication assessments as indicated, not completing Abnormal Involuntary Movement Scale (AIMS) assessments as indicated, and not developing individualized nonpharmacological interventions. The deficiency was identified during interview and record review for two of five residents reviewed for unnecessary medications in a total sample of 44. One resident was admitted with diagnoses including Alzheimer's disease, psychosis, vascular disease, and anxiety. The psychiatrist documented treatment with mirtazapine, sertraline, and Seroquel. The care plan identified the resident as requiring psychotropic medication for psychosis and antidepressant medication for poor appetite, and it listed monitoring interventions and side effects to observe. However, the medical record did not document any AIMS assessments or psychotropic medication assessments. The DON confirmed there were no AIMS assessments or psychotropic medication assessments for this resident and stated there were no other care plan documents showing individualized nonpharmacological interventions. The second resident was admitted with diagnoses of bipolar disorder and depression and had orders for Depakote and sertraline. The record included one AIMS assessment with low risk and another AIMS assessment, but no additional AIMS assessments were documented. The resident's care plan identified psychotropic medication use for mood and behavior and included general interventions such as administering medication as ordered and assessing for behavior or mood changes, but there were no individualized nonpharmacological interventions documented. A psychotropic medication assessment form was present but was not completed or signed, and no other psychotropic medication assessments were documented. The DON confirmed there were no other AIMS assessments or psychotropic medication assessments for this resident and no other care plan documents showing individualized nonpharmacological interventions.
Failure to Provide Ordered Wound Care and Repositioning
Penalty
Summary
The facility failed to ensure that wound care treatments and pressure ulcer prevention interventions, including repositioning and turning, were implemented as ordered for a resident with a coccyx pressure ulcer. The resident had diagnoses including hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side and type 2 diabetes. The wound assessment identified a facility-acquired stage 3 coccyx pressure injury with a care goal to decrease ulcer area and an approach of off-loading and optimizing moist wound healing. The physician orders required cleansing the coccyx wound with saline, applying betadine to the peri-wound, iodosorb gel and calcium alginate to the wound bed, and covering with a dry dressing daily and as needed. During continuous observation, the resident was seen resting supine at 45 degrees from 9:51 a.m. to 12:00 p.m., and the facility staff did not turn or reposition the resident during that time. Staff were observed at the room doorway during the observation period, and one staff member briefly entered and exited the room. When the resident’s skin was observed, both feet had severe dry skin with flaking skin. The resident did not have the sacral wound treatment dressing in place, and the LPN stated she had not been made aware that the dressing was off. The CNA identified as the resident’s aide stated she last changed and turned the resident at 9:30 a.m., did not notify the nurse or wound care nurse that the dressing was not on, and acknowledged she should have reported it. The wound care nurse stated she was not made aware the dressing was not in place and said failure to reposition and failure to keep the dressing in place could contribute to the wound not healing. The DON stated staff were expected to complete rounds, provide incontinent care, and turn/reposition every two hours or as needed.
Inadequate Competency for Enteral Feeding Pump Use
Penalty
Summary
Licensed nurses were not demonstrated to have the competencies and skills needed to safely manage and monitor residents receiving enteral nutrition via feeding pump. The deficiency affected three residents receiving tube feedings: one resident was observed with the enteral feeding pump turned off, another resident was observed throughout the afternoon in a wheelchair and at activities without being connected to the feeding pump, and a third resident was observed in a wheelchair at the nurses' station not receiving enteral feeding. The registered dietitian stated that the enteral feedings were ordered to run over 20 hours daily to ensure adequate nutrition, and reviewed pump totals showing that two of the residents had not received the ordered amounts of feeding and water flushes in the prior 24 to 48 hours. During interview, a nurse could not explain how feeding delivery was communicated between shifts, how the pump was cleared at the end of the shift, how to determine when the resident had received the total ordered amount, or how to check pump settings and amount infused. The DON stated the nurses had received an in-service on the enteral feeding pump one year earlier, but were not competencied on the pump, and that nurses hired after 1/27/25 received 1:1 training during orientation. The facility could not provide documentation that the nurses hired after that date received the training, could not provide documentation that the nurses who missed the in-service received education on the feeding pump, and could not provide documentation that all nurses were competent in using the feeding pump. The facility's tube feeding policy stated that the pump should be cleared at the end of each shift, tube feeding delivered should be documented, and the health care provider should be notified if the tube feeding amount was not infused as ordered.
Failure to Use EBP PPE and Identify a Resident With a G-Tube for EBP
Penalty
Summary
The facility failed to follow its infection prevention and control policy by not using appropriate PPE before entering resident rooms with enhanced barrier precautions (EBP) and providing direct resident care. On 2/17/26, a CNA was observed bringing clean linen into R78's room while wearing gloves but without donning a gown, despite EBP signage on the door and a PPE bin outside the room. The CNA later exited the room carrying soiled linens. On 2/19/26, two restorative aides were observed using a mechanical lift device to obtain R82's weight and did not don appropriate PPE before entering the resident's EBP room. The facility also failed to place R89, who had an enteral feeding pump at the bedside and a gastrostomy tube, in EBP. On 2/17/26, there was no EBP signage on or near R89's door and no PPE bin outside the room. The infection prevention nurse stated that residents with colonized multidrug resistant organisms are placed in EBP, and that residents with indwelling catheters, wounds, intravenous access devices, gastrostomy tubes, and those receiving dialysis are also placed in EBP. The policy dated 07/2025 states that EBP involves the use of gloves and gowns during high-contact resident care activities for residents infected or colonized with multidrug resistant organisms and residents with wounds and/or indwelling medical devices.
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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What surveyors actually found near you
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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 | ★★★★★ | 12 | 1 |
| Elevate Care South Holland | 2.7 mi | ★★★★★ | 13 | 0 |
| Prairie Oasis | 2.9 mi | ★★★★★ | 16 | 1 |
| Pine Crest Health Care | 2.9 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.