Aliya of Homewood

In the surveyor’s words

From the most serious findings on record at Aliya of Homewood, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Jun 17, 2021

  Based on observations, interviews, and record reviews, this facility failed to perform a comprehensive respiratory assessment, recognize the need to implement life sustaining interventions, including providing oxygen therapy, according to professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R1 exhibited abnormal vital signs, decreased oxygen saturation levels, increased heart rate, and labored breathing for 43 minutes before EMS (emergency medical services) was notified. This failure resulted in R1 expiring upon arrival to the hospital. The Immediate Jeopardy was identified from observations and interviews to start on [DATE]. […]

• Actual harm, isolatedF689Mar 26, 2026

  Based 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. […]

• Actual harm, isolatedF692Feb 20, 2026

  Based 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.Findings include: On 2/17/26 at 12:47 PM, R9 received lunch meal tray. R9's head of bed was at 45 degrees. At 1:10 PM, R9 was observed eating one piece of canned fruit. R9 was observed coughing while eating. […]

• Actual harm, isolatedF693Feb 20, 2026

  Based 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. […]

• Actual harm, isolatedF689Jul 18, 2025

  Based 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. […]