Inspection·May 16, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few The Facility Incident Report dated 4/11/25 documents the CNA assisted R2 with ADL care. The CNA reached to position the wheelchair for transfer when R2 reached for eyeglasses on the floor and fell forward, landing on the left side before the CNA could assist R2. The CNA immediately alerted staff for assistance. A body assessment was completed and an open area to the left side of the forehead was noted. First aid was administered and a dry dressing was applied. When interviewed, R2 said, I was reaching. Prior to the incident, R2 was sitting comfortably with the bed in the lowest position. New orders were received to send R2 to the emergency room for further evaluation. R2 was transferred to a different hospital and admitted with a small left subdural hematoma. Repeat CT scan revealed this small hematoma resolved and did not require any surgical intervention. On 5/13/25 at 2:06PM, V2 (CNA) stated V2 was doing morning care and was getting R2 dressed and washed up. V2 sat R2 on the side of the bed and R2 was sitting up. V2 reported R2 reached down on the side of the floor and fell out of the bed. V2 stated V2 always has to coach R2 when V2 is with R2 because R2 has a habit of reaching. V2 reported R2 wasn't a high fall risk at the time of the fall and is a one assist with transfer and walking. V2 stated V2 was facing R2 when R2 was reaching but V2 was setting up the wheelchair so V2 didn't see R2 begin to fall. V2 reported V2 was maybe a foot or two away from R2 when the fall occurred. V2 stated V2 set the wheelchair down right in front of R2 so the wheelchair was in between V2 and R2. V2 reported V2 usually sets up the wheelchair in the way because R2 has never had a problem with falling forward before. V2 stated R2 had a cut to R2's head. V2 was unaware if R2 was in physical therapy at the time of the fall. On 5/14/25 at 11:50AM, R2 was sitting at the dining room table waiting for lunch. R2 stated R2 was comfortable speaking in the dining room. R2 reported having a fall about a month ago. R2 was not able to remember what caused the fall. R2 stated R2 couldn't remember anything until R2 was at the hospital and hospital staff told R2 that R2 fell. R2 pointed to R2's left side of the top of the head and told the surveyor that this is where R2 hit R2's head during the fall. There is a healed scar about 1.5 inches long. R2 was not able to remember if R2 had any other injuries. R2 could not remember who was in the room with R2 during the fall. R2 stated R2 now has a reacher to grab things so R2 won't bend down anymore. R2's mental status was assessed. R2 knew R2's name, birthday, and that R2 was in a nursing facility in Chicago. R2 was unable to state the date or the name of the town. On 5/14/25 at 11:59AM, V4 (Nurse) stated V2 informed V4 that R2 was on the floor so V4 went to assess R2. V4 reported R2 had bleeding coming from the left side of the top of the head and a dry dressing was put on it after the wound nurse looked at it. V4 stated R2 was sent out via 911 per the physician's orders. V4 knew R2 couldn't move one side of the body due to stroke but V4 couldn't remember what side. V4 reported R2 is not a high fall risk and is not confused. V4 stated V2 told V4 that R2 was leaning forward out of the bed and was trying to grab something and fell. V4 was not aware of R2 having that behavior. On 5/14/25 at 1:02PM, V6 (Therapy Director) stated when R2 was in therapy before the fall, R2 was moderate assist with transfers. V6 reported transfers were rough for R2 so R2 was referred to therapy for that reason. V6 stated R2 had fairly good trunk control. V6 reported R2 can follow directions and knows who you are but won't remember what day it is. On 5/14/25 at 1:45PM, V10 (Medical Director) stated a radiologist will report any kind of bleed even if the bleed is small in the brain. V10 reported if there is an area the radiologist sees that is hyperdense focus it means that area of the brain on the scan was brighter than it should have been, but it is usually a really tiny area only millimeters long. V10 stated the hyperdense focus could be from a bleed that has a large sized hematoma to accompany it which would be caused by trauma. V10 (continued on next page) 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 05/16/2025 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 Level of Harm - Actual harm Residents Affected - Few reported if a resident has a certain behavior that puts them at risk of being harmed then it is the responsibility of the facility to prevent any harm from that behavior as best as possible by putting in interventions that address the behavior. On 5/14/25 at 2:07PM, V9 (DON) stated V9 does all the reportable investigations for falls with injury. V9 reported R2 had a witnessed fall with a laceration to the head. V9 stated V2 told V9 that V2 turned to get the wheelchair for R2 when R2 leaned forward and fell before V2 could react. V9 denied R2 remembering the fall. V9 reported R2 was admitted to the hospital so they could rule out a subarachnoid bleed in the brain. V9 stated the subarachnoid bleed was ruled out but R2 needed to stay in the hospital about three to four days for monitoring. V9 was not able to answer if the brain bleed was ruled out then why was it added to R2's diagnoses on the face sheet? V9 said, That is a question for MDS. V9 reported R2 also had a laceration repair of the forehead while at the hospital which has now healed. V9 stated a reacher was put in place after the fall to prevent any additional falls from happening in this manner. V9 reported R2 is a fall risk but not a high fall risk because R2 is not confused. V9 stated R2 does have a history of a stroke with weakness or paralysis to one side. On 5/14/25 at 2:53PM. V13 (MDS Nurse) stated V13 reviews the most recent assessment and plan from the physician in the hospital records upon a resident's return to the facility. V13 reported V13 uses active diagnoses to update the resident's face sheet. V13 stated R2 had a follow up with neurosurgery to see if R2 was able to restart the anti-platelet medication after having the brain bleed. The Fall Report dated 4/5/25 documents the CNA was providing R2 morning ADL care. The CNA just changed R2's clothing and sat R2 on the side of the bed to get R2 into the wheelchair. The CNA reported turning to retrieve the wheelchair when R2 leaned forward from a sitting position at the side of the bed, causing R2 to destabilize and fall forward. R2 struck R2's head on the nightstand before landing on the left side. R2 said, I fell onto the floor. I am OK but my head hurts. R2 denied any other pain or discomfort. R2 is noted with a small laceration to the left forehead with moderate bleeding. 911 was called to take R2 to the hospital for further evaluation. The Hospital Records dated 4/7/25 document R2 has a history of cerebral vascular accident with residual left sided hemiparesis. R2 presented as a trauma transfer for mechanical fall R2 was being transferred from the wheelchair when R2 became lightheaded and fell forward, hitting R2's head but did not lose consciousness. The initial CT scan of the head showed a small subdural hematoma with serial CT scans showing the hematoma was stable. Per neurosurgery, no surgical interventions are recommended, but will continue to hold the anti-platelet medication until follow up. An MRI of the left femur revealed there was no evidence of acute fracture. Assessment and plan documents a mechanical fall with a subdural hematoma. This is the documentation that V13 referenced and showed the surveyor for the diagnosis of subdural hematoma that was entered on R2's face sheet upon return to the facility. The Physical Therapy progress report dated 3/7/25 through 4/2/25 documents R2 is a fall precaution with aphasia and left sided weakness. R2 needs partial/moderate assistance from going from a sitting to standing position and transfers. R2 needs supervision or touching assistance with walking. Picking objects up off the floor is documented as not applicable. Continue therapy is recommended to increase lower extremity range of motion and strength, minimize falls, and promote safety awareness. The note dated 4/2/25 documents skilled interventions focused on instruction in scooting techniques to facilitate upright posture and proper positioning in wheelchair and training and safe sit to stand/stand to sit mobility. The After Visit Summary dated 4/30/25 documents R2 had a follow up with neurosurgery and was (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 05/16/2025 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 cleared to resume the anti-platelet medication. This was a follow up due to the subdural hematoma and fall. Level of Harm - Actual harm The Fall Risk Evaluation dated 11/2/23 documents a score of 15 indicating R2 is at high risk for falls. This assessment was completed post fall. R2 has decreased mobility, is confused/has impaired memory or judgment, is incontinent, and above 75. No other fall risk evaluations were completed again until 4/5/25. This fall risk evaluation document a score of four indicating R2 is not at risk for high fall. A score of 10 or higher makes a resident high risk for falls. When looking at the assessment, it is incorrectly coded, giving R2 a lower score. If the assessment was properly charted, R2 would have a score higher than 10 making R2 a high fall risk. Residents Affected - Few The Functional Abilities and Goals dated 2/7/25 document R2 needs substantial/maximal assistance with bed mobility, going from a sitting to standing position, and transfers. Picking up an object from the floor was not attempted due to medical condition or safety concerns. The Care Plan dated 11/3/23 documents R2 is at high risk for falls related to impaired mobility and strength, decline in cognition, potential medication side effects, unsteady gait, and diagnosis of cerebral infarct with left hemiplegia. Interventions put in place after the fall on 4/5/25 include educate R2 on the importance of complying with safety measures and document understanding of education and instances of noncompliance, encourage use of and provide a reacher as needed to assist R2 with getting items from hard reach areas, and encourage appropriate use of the walker and wheelchair. The Care Plan dated 11/8/23 documents R2 is memory, impaired, and has difficult with decision-making, insight, logic, planning, and organization of thoughts. The Care Plan dated 11/9/23 documents R2 is on antiplatelet therapy and is it risk for adverse side effects. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental status score at 11 (moderate cognitive impairment). Section GG of the MDS indicates R2 has an upper extremity impairment to one side. R2 needs substantial/maximal assistance with bed mobility and transfers. The policy titled, Fall Prevention and Management, dated 2/2025 documents, General: This facility is committed to maximizing each resident's physical, mental, and social well-being. While preventing falls is not possible, the facility will identify and evaluate those residents at risk or fall, plan preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 4 of 4