Inspection·June 21, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement its abuse prevention policy by failure to report injury of unknown origin. This deficiency affects one (R3) of three residents reviewed for abuse prevention policy. Findings include: On 6/18/25 at 4:15PM, R3 was assessed by V4 (Restorative Nurse) and V2 (Director of Nursing) and surveyor present. R3 was observed with discoloration to bilateral side of breasts. On 6/18/25 at 4:30PM, V2 (Director of Nursing) said staff is aware to report any injuries of unknown origin to Administrator to complete an investigation and report to IDPH in a timely manner. V2 said it was not reported to IDPH. On 6/18/25 at 4:30PM, V4 (Restorative Nurse) said any unknown injury is reported immediately for follow up. On 6/21/25 at 10:44AM, V1 said she did not send the initial report to IDPH in a timely manner for an unknown injury incident. V1 said staff is aware to report immediately to V1 for follow up and investigation. V1 said she did not think it was an abuse case, however per facility policy failed to follow protocol. R3 was admitted on [DATE] with diagnosis in part but limited to cerebral infarction, other coronavirus, anemia, type 2 diabetes mellitus, hyperlipidemia, heart failure, essential hypertension. Progress note dated 6/13/25 indicates observation of bruising. Initial report of incident dated 6/18/25 reported to IDPH. Abuse Investigation and Reporting Policy Revised 11/2023. Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the Ascension Living Abuse Prevention policy. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145324 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 06/21/2025 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)