Health inspection·March 7, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few On 1/19/2024, V16 (RN) documented the following: readmitted [AGE] year-old . from hospital via ambulance and two paramedics, resident arrived wearing a cervical collar that must remain in place for 6 to 8 weeks, g-tube placed 01/17, resident is NPO. On 2/29/2024 at 2:45PM, V16 (RN) said that R3 was a very sweet lady, she was bedridden but makes her needs known to staff, she will always ask staff to open her candy and place them on her bedside table, R3 cannot reach further than her bedside table, she cannot reach her drawer, always ask staff to get the candy from her drawer and open them. Prior to the fall R3 does not move and was dependent on staff for ADLs, staff always need assistance to turn and hold her, will say that R3 requires 2-person assistance for ADLs to be on the safe side. R3 came back from the hospital with a G-Tube, a cervical collar and was not doing good, just went downhill. On 2/29/2023 at 1:43PM, V13 (LPN) said that she recalls R3, she was alert and oriented x2, incontinent of bowl & bladder, and non-ambulatory. Resident did not have a G-Tube before the fall, she cannot do much for herself, staff must feed her, resident cannot use her hands and cannot reach to her drawer to get anything. V13 said she would use 2-person assist with R3 for ADLs due to her weight, it depends on the CNA but most of them ask for help. On 2/29/2024 at 1:55PM, V14 (Restorative CNA) said that R3 requires mechanical lift for transfers, she does not get out of bed, she needed 2 people to help her turn, V14 came to work after the resident was sent out to the hospital after she fell. V14 has done range of motion exercises with resident, she came back from the hospital with a neck brace and a G-tube. V14 stated that R3 requires two people to turn her, and she has assisted other CNAs in providing ADL care to R3. R3 did not have any floor mat prior to her fall. On 3/4/2024 at 11:55AM, V19 (LPN/Restorative) said that she oversees fall care plans, the initial fall assessment is done upon admission, quarterly and when there is a fall. R3 requires extensive assistance with ADLs, she was a high fall risk and had interventions like low bed, resident does not have a floor mat before the fall, and there were no additional interventions after the fall. On 3/4/2024 at 4:13PM, V22 (LPN) said that R3 was alert x 1 to 2, she can tell you what she wants and can refuse some stuff sometimes. V22 was not present but was told that staff rolled resident away from her, resident started to reach to her drawer for candy and staff could not pull her back. V22 stated that she in-serviced the CNA about compliance to resident's care plan. R3 was a two-person assist at that time as indicated in her care plan. CNA stated that she was not aware, but resident's level of care is also listed in the [NAME] patient information sheet that is available to the CNAs and it is their responsibility to know the type of care a resident requires. On 3/4/2024 at 3:24PM, V21 (LPN) said that she recalls R3, she was a total care. V21 is not sure if R3 is a fall risk, resident returned from the hospital with a G-tube after the fall, R3 does not get out of bed and did not have any interventions before the fall, resident did not have a floor mat before the fall. On 3/4/2024 at 1:58PM, V20 (CNA) said that she recalls R3, she was a total care, incontinent of bowel and bladder and she has always taken care of her by herself, never called anyone to assist her with the resident. V20 said that she was taking care of R3 the day she fell, she was in the middle of changing resident when she started asking for a candy that the family brings for her. V20 said she had gloves on and told resident to wait for her to finish, resident started reaching to her drawer for the candy and V20 could not reach her to pull her back on the bed. V20 said that she was told that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 2 of 3 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 03/07/2024 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)

F 0689 R3 was a two person assist and that it was in her care plan but at the time she was not aware of that. V20 stated that she was in-serviced after the fall on getting another staff for assistance and resident fall risk. Level of Harm - Actual harm Residents Affected - Few On 3/5/2024 at 12:53PM, V26 (Attending Physician) said that R3 came back from the hospital with a G-tube and cervical collar, resident was alert to self prior to the fall and denies pain, compliant with medications and dependent on staff for ADLs. V26 was asked if R3 declined after the fall and he said, definitely, with a cervical collar and subdural hematoma, resident declined. Fall prevention and management policy revised 1/2024 states in general that the facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing care plan shall be evaluated and modified as needed. Under guidelines, the policy states in part: 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risks identified on the interim plan of care with interventions implemented to minimize fall risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 3 of 3