Inspection·June 11, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few On 6/11/25 at 1:49PM, V10 (Restorative Nurse) said she is familiar with R1 and R1 is a two person assist with activities of daily living and transfers. When using any Mechanical lift machine for transfers staff should be a two person assist. V10 said it is the facility policy when using a mechanical lift that two-person assist is implemented. V10 said all staff gets training prior to working the floor with residents upon hire and agency staff is trained as well. On 6/11/25 at 3:07PM, V11 (Evening Registered Nurse Supervisor) said V9 had called him to assess R1 after R1 falling. V11 said, When I entered the room, R1 was already in bed and no injuries were observed. R1 denied pain. R1 is somewhat confused. V11 said V8 told him R1 had slid off the mechanical lift and had assisted him back to bed, V8 was the only one transferring R1. V11 said when transferring with a mechanical lift the staff are supposed to have a two person assist. On 6/11/25 at 3:15PM, V2 (Director of Nursing) said her expectations of staff are to follow the residents care plan for fall interventions. V2 said that when using a mechanical lift, the standard of care should be a two person assist. The staff is trained during orientation prior to start of working the floor. The interventions are in the resident's profile the CNAs and nurses can access them. They also have the Kardex at the nurse's station for the transfer status. On 6/11/25 at 3:20PM, V1 (Administrator) said her expectations when staff is using a mechanical lift should always be a two person assist per facility policy. V1 said she was unaware that only one certified nurse aide was transferring R1, V1 said she knew about the fall incident. R1's fall incident documented by V11 (Evening Registered Nurse Supervisor) on 5/23/25 at 9:30PM indicated: V8 (Agency Certified Nurse Aide) reported to the nurse that the resident was assisted to bed and at that time V8 instructed the resident to use the grab bar to help him ease himself down to the bed. V8 observed the residents' left foot was on the floor. V8 was unable to give support to put the resident back into bed. Assessment at the time of the fall indicated no injury. The staff monitored resident post-fall for any injuries. No signs of injury and no complaints of any pain until 5/24/25, when resident complained of pain to his left hip. X-ray to hip and pelvis showed a fracture to the left femoral neck. Resident was transferred to the hospital for further evaluation. His vital signs at the time of discharge were observed as follows: BP 160/78 mmHg, pulse 72 bpm, temp 97.5 F, RR 18 breaths/min, and O2 sat rate at 94% on room air. R1 fall incident initial report was sent to IDPH on 5/25/25 at 5:19PM. Final report was submitted to IDPH on 5/30/25 at 3:33PM indicated: On 5/23/2025 a CNA reported to the nurse that R1 was put to bed, and at that time the CNA instructed the resident to use the grab bar to help him ease himself down to the bed. The CNA observed R1's right hand had let go of the grab bar, which caused the resident to slide off of the bed. The CNA observed his left foot was on the floor. CNA was able to give support to put the resident back into bed. Assessment at the time of the fall indicated no injury. The staff monitored the resident post-fall for any signs of injuries. No signs of injury and no complaint of any pain until 05/24-/2025, when R1 complained of pain to his left hip. X-ray to hip and pelvis showed a fracture to the left femoral neck. R1 was transferred to the hospital for further evaluation. His vital signs at the time of discharge were as follows: BP 160/78 mmHG, pulse 72bpm, temperature 97.5F. respiratory rate 18 breaths/min, and oxygen saturation rate 94% on room air. R1's hospital emergency department records dated 5/25/25 to 5/30/25 discharge summary indicated: Left femoral neck fracture, surgical intervention on 5/27/25, no weight bearing to lower left extremity. Patient had called his wife and said that he was dropped into his bed and then after that was complaining of hip pain. Due to dementia, he is a poor historian. Per wife patient has been non (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 2 of 3 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 06/11/2025 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 0689 ambulatory at the nursing home, they use a mechanical lift for mobility in and out of bed. Patient was discharged to nursing home facility on 5/30/25 for skilled therapy. Level of Harm - Actual harm Facility Policy on Mechanical Lifts revised 1/2024. Residents Affected - Few Policy Statement- It is the policy of Ascension Living to use mechanical lift(s) according to current standards of practice and keeping with manufacturer's guidelines. B. The use of the mechanical equipment is considered either as a full body lift or sit to stand lift that aids the resident and associate in transfer and/or care procedures. G. Education shall be provided on the proper use of the assistive mechanical lifting equipment prior to the use. Facility Policy on Falls revised 1/2024. Purpose-To prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with Communities managing fall risk through the process of assessment, planning, implementation, and evaluation (APIE). B. Residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk. Facility Policy on Fall Prevention revised 7/2023. Policy Statement- The intent of this policy is to provide an environment that is free from accidents hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145324 If continuation sheet Page 3 of 3