Inspection·July 5, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interviews and record reviews, the facility failed to follow its fall prevention and management policy and accurately assess a resident's fall risk and implement high fall risk interventions to reduce the risk of falling for a resident identified as impaired safety awareness. This affected 1 of 3 residents (R1) reviewed for fall prevention. Findings include: On 6/29/23 at 12:30pm, R1's family member stated that prior to R1's fall on 6/17/23, there were no fall precaution interventions in place for R1. R1's family member stated that staff were aware on 6/15/23 when R1 was admitted that R1 was at high risk for falls. R1's family member stated that R1 was wearing a fall risk identification band from the hospital on her right wrist. R1's family member stated that R1 sustained bruising to both eyes and right forehead due to fall. On 6/30/23 at 11:45am, V2 DON Director of Nursing) stated that V2 is responsible for this facility's falls program. V2 stated that three days ago V2 realized that the nursing staff were not considering the fall risk assessment score when implementing fall risk interventions. V2 stated that V2 has started re-educating staff on assessing a resident's fall risk and implementing appropriate interventions based on the assessment. V2 stated that a fall risk score of 0-9 indicates the resident is at risk for falls. V2 stated that a score of 10 or higher indicates the resident is high risk for falls. V2 acknowledged that high risk for fall interventions were implemented after R1's fall. Review of R1's medical record notes R1 was admitted to this facility on 6/15/23 with diagnoses including, but not limited to, unsteadiness on feet, abnormalities of gait and mobility, weakness, and Alzheimer's disease. Review of R1's physical therapy note while in hospital, dated 6/15/23, notes R1's attention span is impaired as evidenced by agitation, distractibility, and reduced memory. R1 follows one step commands inconsistently. R1's safety awareness/insight is impaired. Review of R1's physical therapy evaluation, dated 6/16/23, notes R1 requires moderate assistance of staff with bed mobility (roll left and right), sit to lying position, and lying to sitting on side of bed. R1 requires maximum assistance of staff for sit to stand. Ambulation not attempted due to medical condition/safety concerns. R1's mobility function score is 2 (range 0-12; 12 being the highest function). Bilateral lower extremity strength impaired. R1's decision making ability for routine activities is severely impaired. Review of R1's progress notes, dated 6/17/23 at 11:45am, V6 LPN (Licensed Practical Nurse) noted (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145684 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)