Health inspection·February 23, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to access EMS (Emergency Medical Services) for one of one residents (R1) reviewed for change in condition in a total sample of three residents. Residents Affected - Few Findings include: R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on 12.12.2024, with diagnoses including but not limited to: Intrahepatic Bile Duct Carcinoma, Acquired Total Absence of Pancreas, Muscle Wasting and Atrophy, Adult Failure to Thrive, Type 2 Diabetes Mellitus, and Hypertension. R1's MDS (Minimum Data Set of 12.14.2024) documents R1 is moderately cognitively impaired. 1.6.2025, 9:00 PM, General Progress Note documents in part: 3:30 PM- noted resident lying on bed comfortably. No respiratory distress noted. Vital signs taken as follows BP 110/ 64, respiratory rate 20, heart rate 84, oxygen level 92% RA (room air), temperature 98.7, blood sugar 128. Due meds given and well tolerated. At around 5:00 PM, NOD (Nurse On Duty) made a quick round and noted resident verbalized that he feels nauseated. vital signs taken, BP (blood pressure)104/61, HR (heart rate) 97, temperature 100.5, oxygen 89% RA (room air), RR (respiratory rate) 20. The physician was updated and made an order to put resident on oxygen treatment, start an IVF (intravenous fluid) treatment for hydration and STAT (immediate) lab works. At around 5:30 PM, resident's vitals were taken as follows BP 114/ 67, RR 20, HR 91, Temp 98.6, O2 96% via nasal cannula. Resident is easily arousable to tactile stimuli. 1.6.2025, 11:55 PM, General Progress Note documents in part: 11:00 PM, received resident in bed, on moderate high back rest, awake, not in distress, with oxygen inhalation via nasal cannula at 2LPm (liters per minute). Resident denies any discomfort. Vital taken as follows; BP 98/56, HR 92, RR 18, 02 sat-98%. At 11:53 PM NOD (nurse on duty) received chest x-ray result and relayed results to the physician. New orders made and carried out. 1.7.2025, 3:35 AM, General Progress Note documents in part: 1:45 AM, routine rounds made. Resident is alert and sleeping with interval, appear weaker. Vital signs taken as follows: BP 88/ 56, HR-89, RR -17, 02 sat-98%. Placed resident in Trendelenburg position. Physician made aware. Orders made & carried out. At 2:00 AM- vital signs rechecked. BP-68/52, HR-91, RR-18, 02 sat 97% VNC (via nasal cannula). Resident is easily arousable to tactile stimuli. Not in distress. Incontinent care done by staff. Physician made aware and order given to transfer the resident to hospital emergency department. Called (private) ambulance. At 3:15 AM-(Private) ambulance arrived. At 3:28 AM, resident left the facility via stretcher accompanied by 3 paramedics going to (local) hospital ER; remains awake, (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: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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)