Aliya of Homewood

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that required fall prevention interventions were on the care plan, failed to implement fall prevention interventions, failed to ensure that risk assessments were accurate, failed to ensure that staff were aware of resident falls/injury, failed to ensure that staff were aware of resident transfer requirements, and/or failed to provide supervision to four of four residents (R2, R3, R4, R5) reviewed for falls. These failures resulted in the following serious injuries; R5's (3/16/26) fall with sustained head laceration - requiring staple repair and R4's (2/6/26) fall with sustained eyelid laceration. The facility also failed to ensure that physical assessments (post fall) were accurate.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures, failed to ensure that resident risk assessments were completed, and failed to ensure that a risk assessment was accurate for one of four residents (R4) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to follow policy procedures and failed to ensure that required diagnoses/interventions were included in the baseline care plan for one of four residents (R2) reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician and registered dietitian of a resident's poor appetite and decreased oral intake, which resulted in significant weight loss, and failed to implement timely interventions to prevent further decline. This affected one of three residents (R9) reviewed for nutritional status in a sample of 44 residents. This failure resulted in R9 experiencing a significant unplanned weight loss of 13.3% over a three-month period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were at risk for malnutrition and dependent on enteral feedings received nutrition as ordered to maintain adequate nutritional status and prevent weight loss. The facility also failed to ensure staff demonstrated competency in the administration and management of enteral nutrition and care. This affected 2 of 3 residents (R82 and R89) reviewed for enteral nutrition in a sample of 44 residents. As a result, R82 experienced a significant weight loss of 14.1% between July 2025 and February 2026, and R89 experienced a weight loss of 4.4% within eight weeks of admission.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to follow its call light response policy and ensure the call light cord was within reach for 4 residents (R60, R91, R114, and R126) out of 4 residents reviewed for call light accessibility in a sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received timely incontinence care, hygiene, and skin care services at least every two hours to maintain cleanliness, prevent skin breakdown, and promote comfort. This affected five of six residents (R126, R9, R89, R44, and R11) reviewed for activities of daily living (ADL) care, incontinence care, and hygiene/skin care in a sample of 44 residents. On 2/17/26 at 12:45 PM, V20 CNA (certified nurse aide) stated that R126 was last changed at 6:30 AM when V20 started her shift today. On 2/20/26 at 11:15 AM, V2 DON (director of nursing) stated that staff are expected to provide incontinence care to their assigned residents every two hours and as needed. R126: On 2/17/26 at 12:20 PM, R126 stated that R126 needs brief changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with facility policy and accepted standards of practice. Specifically, opened and used medications located on the medication cart were not dated upon opening. This affected four of four residents (R 39, R140, R82, and R58) reviewed for medication storage. Finding Includes:On [DATE] at 3:59pm, during a medication cart audit with V14 (nurse), R39 was observed with an Latanoprost eye drops opened and not dated. V14 said, R39's eye drops are open, used and not dated. V14 said, R39's eye drops should have been dated upon opening. Dating the medication is to ensure its not administered past the expiration date. R39 was diagnosed with Glaucoma. R39's physician order sheet documents Xalatan Ophthalmic Solution. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychotropic medications prior to administration for two of two residents (R3 and R113) reviewed for resident's rights in a total sample of 44 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their Psychotropic Medication Program by not conducting psychotropic medication assessments as indicated, not conducting Abnormal involuntary movement scale assessments as indicated and failing to develop individualized nonpharmacological interventions for two of five residents (R104 and R113) reviewed for unnecessary medications in a total sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that wound care treatments and pressure ulcer prevention interventions, including repositioning and turning, were implemented as ordered. This affected one of eight residents (R11) reviewed for pressure ulcers in a sample of 44 residents R11's face sheet shows diagnosis of hemiplegia, hemiparesis following cerebral infraction affecting left non dominate side, type two diabetes. R11's wound assessment dated [DATE] shows coccyx wound, type; pressure, source; facility acquired, clinical stage;3, date identified 2/28/2023, care goal; decrease ulcer area, approach; off-loading, optimizing moist wound healing. On 2/19/26 at 9:51am during continuous observations from 9:51am to 12:00pm R11 was observed resting on her back in supine position at 45 degrees (position confirmed by V30-LPN). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses demonstrated the competencies and skills necessary to safely manage and monitor residents receiving enteral nutrition via feeding pump, in accordance with professional standards of practice, placing residents at risk for complications related to improper administration and monitoring of enteral feedings. This affected three of three residents (R4, R82, R89) who were receiving enteral nutrition in a sample of 44 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its infection prevention and control policy and don appropriate PPE (personal protective equipment) prior to entering resident rooms with enhanced barrier precautions and providing direct resident care. The facility also failed to place a resident with a gastrostomy tube in enhanced barrier precautions. These failures affected three residents (R78, R82, and R89) out of 6 residents reviewed for infection control in a sample of 44.

Inspectors wroteBased on interviews and record review, the facility failed to prevent an injury of unknown origin which occurred for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an undetermined injury of an acute left humeral neck with displaced transverse fracture. Findings Include:R1's referral package dated 8/17/22 documents: past medical history of falls, osteoporosis and closed hip fracture. R1 was admitted with the diagnosis of Age-Related Osteoporosis without current pathological fracture. Minimal data set section C (Brief interview for mental status) dated 6/3/25 document a score of four (4) which indicates severe cognitive impairment. Section GG (functional abilities) documents: R1 required substantial/maximal assistance with upper body dressing, the ability to dress and undress above the waist: [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident (R2) sitting on the side of the bed when preparing R2 for a transfer when R2 reached for an item on the ground causing R2 to fall off the bed for one out of three residents reviewed for falls in a total sample of eight. The failure resulted in R2 needing to be hospitalized after suffering a laceration to the head and a subarachnoid hemorrhage. Findings Include: R2 is an [AGE] year old with the following diagnosis: traumatic subdural hemorrhage, aphasia, hemiplegia affecting the left side, glaucoma, and cognitive communication deficit. Nursing note dated 4/5/25 documents the CNA reported to the nurse that as the CNA was turning to grab R2's wheelchair, R2 fell forward from a sitting position on the side of the bed. R2 struck R2's head on the nightstand before landing on the floor on the left side. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteA. Based on interview and record review, the facility failed to follow physician orders by not obtaining a urinalysis and culture for one resident who was identified as being incontinent of urine with a new onset of lethargy. This affected one of three residents (R4) reviewed for physician orders. This failure resulted in R4 being sent to the hospital with a diagnosis of urinary tract infection and sepsis. B. Based on interview and record review, the facility conduct a comprehensive body assessment on a resident observed with his left leg/knee contorted under his wheelchair, facial grimacing and yelling out with movement. This affected one of three residents (R3) reviewed for quality of nursing and assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective individualized fall interventions to include supervision/monitoring and reduce the risk of multiple falls. This affected two of three residents (R2, R8) reviewed for falls prevention interventions. This failure resulted in R2, who had a diagnosis of Dementia and Alzheimer's disease and identified as high fall risk sustaining a second unwitnessed fall from bed requiring hospitalization for an acute comminuted displaced fracture of the bilateral nasal bones and one centimeter lip laceration. In addition, the facility left R8 unsupervised on the floor for 13 minutes following an unwitnessed.

Inspectors wroteBased on interview and record review, the facility failed to notify their physician of an acute change in condition as noted in their change in condition policy. This failure affected one of three residents (R3) reviewed for change in condition. The failure contributed to a delay in treatment orders for R3 of over 24 hours. Findings Include: On 7/25/24 at 3:13PM, V10 (Nurse) said, V13 (CNA) updated her that R3 was yelling when V13 touched his left leg. R3 had a history of left knee pain. V10 said, R3 allowed her to move his left leg. R3 was in pain, and grimaced when she attempted to reposition R3 in the wheelchair. V10 said, she is not sure what happen after that because she ended her shift earlier than scheduled. V10 said, R3 was sent to the hospital the following day. V10 said, she thought R3 was having knee pain. On 7/25/24 at 3:30pm, V13 said, she was passing dinner trays. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their internal refund process policy by not providing a refund of $19, 950.00 within 30 days from the death or discharge date . This affects one resident (R1) of three residents reviewed for misappropriation of resident's funds. Findings Include: R1 admitted in the facility on [DATE] under hospice private pay and expired in the facility on [DATE]. On [DATE] at 12:35PM V3 (Senior Business Manager) stated, private pay put one month and one month deposit, prior to admission or the day of admission. The rate is $21,000 down for private pay and for semiprivate room, this is for one month payment and one month deposit. V3 stated that they have 30 days to send the refund check to resident and family once the resident has been discharged or expired in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure housekeeping staff inspected the privacy curtains in resident rooms and removed visibly soiled privacy curtains. This failure has the potential to affect 5 (R2, R3, R4, R5, and R6) residents reviewed for a clean, comfortable, homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to have effective fall interventions in place for a resident assessed to be at risk for falls and failed to provide two staff assist when providing assistance with Activities of Daily Living (ADL) per the resident's plan of care. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a fall while being provided with care from one staff and resulted in R3 being transferred to the hospital and diagnosed with a subdural hematoma measuring 2mm. R3 subsequently returned to the facility with a neck collar and gastrostomy feeding tube (G-Tube).

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow manufacturer's guidelines for dating a multidose vial when opened. This deficiency has the potential to affect all 109 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their menu and failed to provide appropriate and approved menu changes and substitutions. This failure has the potential to affect 108 residents who are currently receiving meals and dietary services in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies on food service sanitation and storage by not taking temperatures prior to the start of meal service; failed to ensure the freezer temperature is at 0 degrees or below; failed to place dirty dishes separate from clean dishes; and failed to confirm sanitizer bucket PPM was suitable for use. This failure has the potential to affect all 108 residents who are currently receiving meals and dietary services in the facility.

Inspectors wroteA. Based on interviews and record reviews, the facility failed to follow its policy on water management program related to prevention of Legionella organism in the water system by not treating positive testing sites and not immediately obtaining treatment recommendations. This deficiency has the potential to affect the 109 residents currently residing in the facility. B. Based on observation, interview, and record review, the facility failed to ensure that staff practice appropriate hand hygiene as outlined in their medication administration policy and failed to ensure that staff appropriately dispose sharps in a sharp disposal container. This failure affected two (R39 and R79) of five residents reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dependent residents are assisted with getting out of bed and failed to provide assistive device for a resident (R86) who was assessed as being at risk for complications due to musculoskeletal problems. This failure affected four (R28, R86, R89 and R98) of nine residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were able to engage in the Activity Program upon request and failed to assess for recreation and activity needs upon admission. This failure affected two (R89 and R98) of 44 residents reviewed for activities.