Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure the antibiotic prescribed
include duration, care plan, and documentation of long term used. This deficiency has the potential to affect
1 of 2 residents (R103) reviewed for antibiotic use in a sample of 23.
Residents Affected - Few
Findings Include:
On 11/12/2024 at 12:31PM, R103 on Enhanced Barrier Precaution (EBP). R103 said he takes medication
for infection. On 11/14/2024 at 01:02PM, R103 said he knows he is on antibiotic medication for infection but
does not know the name and has been taking it since he came to facility in September 2024.
On 11/14/2024 at 10:35AM, V4 (Infection Control Nurse) said R103 is prescribed antibiotic, Metronidazole,
should include a start and stop date along with indication for use. V4 said as part of Antibiotic Stewardship
program, V4 review all antibiotic prescribed within a day or two of admission and communicate to the doctor
if the duration is not indicated and document on resident medical records. V4 said the antibiotic prescribed
for R103 on September admission should have a stop date.
On 11/14/2024 at 10:58AM, V2 (Director of Nursing/DON) said all antibiotic should have a start and stop
date along with indication for use. Doctor should be informed if duration is not indicated. R103
Metronidazole antibiotic should have a stop date and not indicated for long term used.
On 11/14/2024 at 01:05PM, V14 (Licensed Practical Nurse/LPN) said she is a regular on the unit where
R103 resides but do not give antibiotic to R103 on her shift. V14 reviewed physician order with Surveyor
which include the Metronidazole antibiotic. V14 said there should have been a stop date for the antibiotic.
admission Record: Diagnosis Information: Sepsis, Unspecified Organism
Order Summary Report: Metronidazole Oral Tablet 500 MG (Metronidazole) Give 1 tablet by mouth every
12 hours for Bacterial Infection, Order date - 9/25/2024, Start date - 9/26/2024, no End date.
Care Plan (Created on 11/14/2024) Focus: R103 is on Antibiotic Therapy r/t bacterial infection.
Policy:
Guideline: Antibiotic Stewardship
Review Date: 2/2024
(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 4
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
11/15/2024
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Policy: It is the policy of . to maintain an Antibiotic Stewardship Program with the mission of promoting the
appropriate use of antibiotics to treat infections and reduce possible adverse events associated with
antibiotic use. Components of the policy were developed by using evidence-based practice guidelines and
are aligned with the Core Elements of Antibiotic Stewardship for Nursing homes, published by Centers for
Disease Control and Prevention (CDC)(1), and State Operations Manual (Appendix PP): Guidance to
Surveyor of Long Term Care Facilities, published by CMS (2).
Prescribing record keeping:
Dose, duration, route, and indication of every antibiotic prescription MUST be documented in the medical
record for every resident.
Records will be reviewed monthly to assess compliance with this requirement, as well as prescription
appropriateness for the individual resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145684
If continuation sheet
Page 2 of 4
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
11/15/2024
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to implement ongoing monitoring of antibiotics.
This deficiency affects one (R103) of three residents in the sample of 23 reviewed for Antibiotic
Stewardship Program.
Residents Affected - Few
Findings include:
On 11/14/2024 at 10:36AM, V4 (Infection Preventionist) said that she reviews the antibiotic medications
prescribed weekly and an infection assessment evaluation is done prior to the start of antibiotic use for the
purpose of monitoring for the antibiotic stewardship program. V4 said that R103 is currently on
Metronidazole 500mg every 12hours for bacterial infection with no stop date. V4 said she is unable to locate
R103's infection assessment evaluation record upon start of antibiotic.
On 11/14/24 at 1:58PM, V2 (Director of Nursing) said that her expectations for the antibiotic stewardship
program should be an ongoing monitoring of antibiotics.
R013 admitted on [DATE] with diagnosis listed in part but not limited to sepsis unspecified organism,
periprosthetic fracture around internal prosthetic left knee joint, subsequent encounter. Active physician
order sheet indicates: Metronidazole tablet 500 MG every 12 hours for bacterial infection started on
9/26/24.
Facility's policy on Antibiotic Stewardship Program indicates: Reviewed 2/2024.
It is the policy of . to maintain an Antibiotic Stewardship Program with the mission of promoting the
appropriate use of antibiotics to treat infections and reduce possible adverse events associated with
antibiotic use. Components of the policy were developed by using evidence-based practice guidelines and
are aligned with the Core Elements of Antibiotic Stewardship for Nursing Homes, published by Centers for
Disease Control and Prevention (CDC) (1), and the State Operations Manual (Appendix PP): Guidance to
Surveyors of Long-Term Care Facilities, published by CMS (2).
Actions
Prescribing and record keeping.
-Dose, duration, route, and indication of every antibiotic prescription MUST be documented in the medical
record for every resident, regardless of prior prescriptions or documentation elsewhere (e.g., in medical
record of a discharging facility). Notation of this information should be made on the day that an in-house
prescription is written or on the day that a resident returns to the facility on an antibiotic prescribed
elsewhere.
-When a new antibiotic is prescribed, the receiving nurse will open a new case in the PCC Infection Control
module and an Antibiotic therapy form in PCC.
-Records will be reviewed monthly to assess compliance with this requirement, as well as prescription
appropriateness for the individual resident, site, and type of infection.
-Assessment of residents suspected of having an infection. Providers will utilize the McGeer's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145684
If continuation sheet
Page 3 of 4
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
11/15/2024
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 0881
Criteria or the Loeb Criteria for initiating Antibiotic usage.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145684
If continuation sheet
Page 4 of 4
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0325GeneralS&S Epotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
FAQ · About this visit
Common questions about this visit
What happened during the November 15, 2024 survey of ALIYA OF HOMEWOOD?
This was a inspection survey of ALIYA OF HOMEWOOD on November 15, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALIYA OF HOMEWOOD on November 15, 2024?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguish..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.