Inspection·April 6, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few it on the bed and sat on it. I pressed call button at 4:15 (AM) and a woman came in with her winter coat on and was yawning and I told her about my diaper and told me to sit on it again. She started pulling and ripped it to shreds. She left and came back with another one and said turn over and she put her fist and pushed me so hard I said stop you're going to push me on the floor. Then she turned me to the other side and pushed me again and I said stop and take blanket off me and then she left. I asked her name 3 times, and she would not tell me. So, 10 minutes later I put call button and said I want someone else here. She says no and I said I want to tell them you're about to push me off the bed. She says you're still on the bed, I said, oh you're now getting smart with me and she leaves and on her way out she says Do not put call button on, so I did anyway because I thought maybe someone else was on duty but she did not come back for 1/2 hours . On 4/4/25 at 11:00 AM, V10 (family member) stated that she never received a call pertaining to the incident involving the CNA V8 but rather was only informed to come in to the facility to sign papers about her mom receiving continued therapy and to obtain payer information. V10 stated when she came in to the facility around 1:30 PM on 3/7/25 her mom started crying to her and informed her that some staff person pushed her while in bed, punched her in the back, and then threatened her to not use the call light. V10 said she immediately went to tell the nurse to call the police and that was when V1 administrator came in to talk to her about the incident. V10 said she was upset that no one told her about what had happened to her mother until she came in to visit and that V1 appeared very nonchalant and indicated she would handle the situation after she had her lunch. V10 said, My mom said she wanted to go home because she didn't feel safe and that no one was around all night to protect her, so I took her home. On 4/4/25 at 12:30 PM, V4 (RN) stated upon telephone interview, What happened was I was drawing blood for the whole house when I received (R1) she was in her chair next to her bed. She looked very distraught and was crying. It was about 5 or 6 in the morning because I was drawing every body's blood and I started around that time. The resident was trying to explain to me what happened, and she looked very guarded, almost as if she was in shock. She explained that V8 CNA on duty told her she should not ring the bell until the end of her shift or until she left. The resident is very alert, so she came across very credible, so I let the charge nurse V5 know when I saw him walk by and told him that we have a situation here and told him to come into the room. I told him because he was the supervisor at night. I have never seen this agency CNA before as there's been so much Agency staff lately. (R1) identified the CNA and I saw her just sitting by the couch near the nurses station. She had her stuff with her already like bags, notebooks and she had her winter coat on. We actually asked her to leave about 20 minutes to 7 AM after we called the administrator. Initially (V1-Administrator) didn't pick up but then she eventually called the facility back and said to write a statement later and so I did that and left. Surveyor asked if V4 did anything else with the resident to determine if she had any visible injuries or felt safe. V4 said, I don't recall and I'm not familiar with the policy in that facility because I'm mostly PRN (as needed) and I don't get involved in the whole thing like this. Surveyor asked if V4 called the police. V4 said, No I didn't call the police because I'm not familiar with their policies here. I just called the nurse in charge, and he called the administrator. Surveyor asked if V4 assessed the resident for any injuries. V4 stated, I don't know, everything went so fast, and I probably should have but no I didn't. A written statement signed by V4 dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she (R1) was in tears and when I asked her why, she stated that she was scared. I asked her why she was scared. She (R1) responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like, and it matched what she described. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 2 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0600 Level of Harm - Actual harm Residents Affected - Few Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) There was no written statement taken by V1 (Administrator and abuse prohibition coordinator) for V5 (LPN night supervisor) who was directly involved during R1's initial reporting of allegation of abuse. Surveyor however was able to interview V5. On 4/4/25 at 12:40 PM, telephone interview with V5 (LPN night supervisor) said, There was an incident where an agency CNA was assisting a patient (R1). The nurse on duty (V4) called my attention to R1's room about a concern that the patient was scared about an Agency CNA. R1 described the CNA as African American, tall, wearing coat. I asked V4 what happened, and he described what the patient told him. What I can get from the nurse was that when the patient was being changed, she had a feeling she was going to fall from the bed during a diaper change. I guess she was being pushed too far at end of the bed and she was scared of the CNA and while being changed was pushed or hit by the CNA. When this all happened, I guess I was basically on 2nd floor doing rounds. I've been here since 2005 and this is the first time this has ever happened. The patient is very alert and is not confused at all. She was here for rehab. When I saw R1, she appeared very frightened and shaken up by the whole thing I could tell. Surveyor asked V5 if there was any assessment conducted. V5 said, No I don't recall doing that. We got so busy getting information from her and we called the administrator and left a message for her and by the time she called back, it was may have been about a quarter to 7 and the CNA (V8) was going home soon anyway but yes, I should have made sure V4 assessed her to see she was uninjured. Surveyor clarified if there was any nursing assessment conducted as V1's abuse incident report indicated that there was one done. V5 stated, No I don't recall that. Surveyor asked if the physician or family was notified of the incident. V5 said, No I didn't call the family or doctor, we just called the administrator. I'm just supposed to call the administrator and I haven't encountered this situation before, so I didn't know what to do. On 4/4/25 at 10:40 AM, V9 (Human resource director) said, I don't handle agency staff paper work or trainings, just our own. We don't screen agency staff; they do the screening for us. Surveyor asked if agency staff screenings were reviewed by her, V9 said, No I don't review any of their staff that they send, I didn't know I had to. Surveyor requested to have V8's hire records and trainings provided to her by her agency, but no records were provided during the investigation. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (Doctor) could not be reached for interviews during this investigation after several attempts were made. Facility interdisciplinary notes showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 3 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0600 Level of Harm - Actual harm Residents Affected - Few facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or psychosocial assessment, if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 4 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to thoroughly investigate and interview staff; failed to interview potential residents that may have been affected by the alleged abuser in the investigation; and failed to assess resident for any obvious injuries after the alleged abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. An initial and final report dated 3/7/25 written by V1 (administrator/abuse prohibition coordinator) reads in part, Allegation of abuse and internal investigation: At 6:00 AM when the night nurse went into the resident's room, she informed the nurse she was upset because she felt the CNA assigned to her was inappropriate with her verbally and treated her roughly when helping her to turn in bed during incontinence care. When she put her call light on at around 4:00 AM, the CNA entered the room and said, What do you want? Then, while providing incontinence care, the resident felt the CNA was pushing her over too hard and this made her concerned she was going to roll off the bed onto the floor when she was turned. After the incontinence care, the CNA then told the resident to not press the call light again and left the room. The resident asked the CNA three times if she could have her name, but the CNA refused to answer that question. This was the only time she interacted with the CNA. Immediately after the resident reported the incident to the nurse, the nurse notified the Executive director (V1) The executive director directed the nurse to have the CNA leave the facility immediately. A Body check was done, and there was no redness or bruising noted. The resident's physician was notified. The resident is alert and oriented and declined the executive director notifying her family, because she stated she wanted to inform them herself. A comprehensive internal review, including resident reviews, yielded no evidence of abuse. The local police were notified of the allegation and came to the facility at approximately 3:30 PM to interview the executive director, the resident and her daughter who was present during their visit to the facility. Surveyor's interviews of staff and nursing records provided are not consistent with V1's initial and final report of abuse allegation: On 4/4/25 at 1:40 PM, V1 (Administrator and abuse prohibition coordinator) stated, I didn't interview or get statements from V5 night supervisor, but I did speak to both (V5) and (V4) the nurse on duty because they both called me together on the phone, but I guess I should have gotten a statement/interview from V5 himself. I didn't interview any other staff because they were on different assignments but you're correct, I could have done that to see if they heard anything. Surveyor asked if she tried to interview V8 who was involved in the incident, V1 stated, No I did not interview the agency CNA. On 4/4/25 at 11:15, V7 (Staffing Agency manager) said, I was only reported by the facility to not send (V8) to go back to the same place is what I do. We DNR (Do Not Return) the staff person and report that there was an allegation of abuse and ensure to block them from picking up at any of V1's other facilities. We did not interview the CNA in question, we just remove them from picking up shifts. We do not investigate situations like this nor report it to the CNA registry. We leave that to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 5 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0609 facility reporting the allegation. Level of Harm - Minimal harm or potential for actual harm On 4/4/25 at 11:25 AM, V3 (Facility staffing scheduler) provided surveyor with list of residents on each unit where V8 worked the night of the incident and on previous shifts and units that V8 had worked on. A review of the V1's internal investigation showed 5 other residents interviewed but were not within the same unit as R1 where V8 had worked. There were no other staff members interviewed who were working during V8's shift. Residents Affected - Few On 4/4/25 at 11:55 AM, V2 (DON Director of Nursing) said, I am the interim DON and have been here since last December and what should happen is usually, I would be informed of incidents like this and especially pertaining to allegations of abuse. However, I was not, and I should have been. I had no involvement in the investigation whatsoever, but yes these nurses do fall under my direction, and I should be kept informed however unfortunately I was not. A written statement signed by V4 (RN nurse on duty) dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she was in tears and when I asked her why she stated that she was scared. I asked her why she was scared. She responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like, and it matched what she described. Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) Facility interdisciplinary notes provided to surveyor during this investigation showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (Doctor) could not be reached for interviews during this investigation after several attempts were made. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 6 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0609 psychosocial assessment, if needed. 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: 145324 If continuation sheet Page 7 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate and interview staff; failed to interview potential residents that may have been affected by the alleged abuser in the investigation; and failed to assess resident for any obvious injuries after the alleged abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. Residents Affected - Few Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. An initial and final report dated 3/7/25 written by V1 (administrator/abuse prohibition coordinator) reads in part, Allegation of abuse and internal investigation: At 6:00 AM when the night nurse went into the resident's room, she informed the nurse she was upset because she felt the CNA assigned to her was inappropriate with her verbally, and treated her roughly when helping her to turn in bed during incontinence care. When she put her call light on at around 4:00 AM, the CNA entered the room and said What do you want? Then, while providing incontinence care, the resident felt the CNA was pushing her over too hard and this made her concerned she was going to roll off the bed onto the floor when she was turned. After the incontinence care, the CNA then told the resident to not press the call light again, and left the room. The resident asked the CNA three times if she could have her name, but the CNA refused to answer that question. This was the only time she had interaction with the CNA. Immediately after the resident reported the incident to the nurse, the nurse notified the Executive director (V1) The executive director directed the nurse to have the CNA leave the facility immediately. A Body check was done, and there was no redness or bruising noted. The resident's physician was notified. The resident is alert and oriented and declined the executive director notifying her family, because she stated she wanted to inform them herself. A comprehensive internal review, including resident reviews, yielded no evidence of abuse. The local police were notified of the allegation, and came to the facility at approximately 3:30 PM to interview the executive director, the resident and her daughter who was present during their visit to the facility. Surveyor's interviews of staff and and nursing records provided are not consistent with V1's initial and final report of abuse allegation: On 4/4/25 at 1:40 PM , V1 (administrator and abuse prohibition coordinator) stated, I didn't interview or get statements from V5 night supervisor but I did speak to both (V5) and (V4) the nurse on duty because they both called me together on the phone, but I guess I should have gotten a statement/interview from V5 himself. I didn't interview any other staff because they were on different assignments but you're correct, I could have done that to see if they heard anything. Surveyor asked if she tried to interview V8 who was involved in the incident, V1 stated, No I did not interview the agency CNA. On 4/4/25 at 11:15, V7 (Staffing Agency manager) said, I was only reported by the facility to not send (V8) to go back to the same place is what I do. We DNR (Do Not Return) the staff person and report that there was an allegation of abuse and ensure to block them from picking up at any of V1's other facilities. We did not interview the CNA in question, we just remove them from picking up shifts. We do not investigate situations like this nor report it to the CNA registry. We leave that to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 8 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0610 facility reporting the allegation. Level of Harm - Minimal harm or potential for actual harm On 4/4/25 at 11:25 AM, V3 (facility staffing scheduler) provided surveyor with list of residents on each unit where V8 worked the night of the incident and on previous shifts and units that V8 had worked on. A review of the V1's internal investigation showed 5 other residents interviewed but were not within the same unit as R1 where V8 had worked. There were no other staff members interviewed who were working during V8's shift. Residents Affected - Few On 4/4/25 at 11:55 AM,.V2 (DON Director of Nursing) said, I am the interim DON and have been here since last December and what should happen is usually I would be informed of incidents like this and especially pertaining to allegations of abuse, however I was not and I should have been. I had no involvement in the investigation whatsoever, but yes these nurses do fall under my direction and I should be kept informed however unfortunately I was not. A written statement signed by V4 (RN nurse on duty) dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she was in tears and when I asked her why she stated that she was scared. I asked her why was she scared. She responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like and it matched what she described. Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) Facility interdisciplinary notes provided to surveyor during this investigation showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (doctor) could not be reached for interviews during this investigation after several attempts were made. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 9 of 10 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 145324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Park Ridge 1001 North Greenwood Avenue Park Ridge, IL 60068 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 0610 psychosocial assessment, if needed. 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: 145324 If continuation sheet Page 10 of 10