Health inspection·September 8, 2023

F 0550 1. The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. 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: 145893 If continuation sheet Page 2 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure call lights where within reach for four (R58, R62, R290, and R293) of six residents in a sample of 25 residents reviewed for call lights. Residents Affected - Some Findings include: 1. On 9/5/2023 at 7:30 AM, R58 and R62 were observed in bed with R58's call light hanging off the side of the bed and R62's call light behind her mattress, out of reach for the residents. On 9/5/2023 at 7:35 AM, V14 (Nursing Assistant) said all call lights should be attached to the resident's chest. On 9/5/2023 at 1:50PM, V2 (Director of Nursing) said all call lights should be within reach of every resident. Physician order sheet dated 8/24/2020 indicates that R58 has a diagnosis of hemiplegia and hemiparesis' following cerebra infraction affecting left non-dominant side and functional quadriplegia. Care-plan update 8/28/20 indicates R58 At risk for falls due to impaired balance/poor coordination, potential medication side effects, unsteady gait, recent fall. Place call light within easy reach; clip call button to pt.'s gown. Physician order sheet dated 12/10/2022 indicates that R62 has a diagnosis of abnormalities of gait and mobility, history of falling and specified disorder of muscle. A care-plan update 8/12/2022 indicates R62 is at risk for falls due to impaired balance/poor coordination. Facility policy Titled Call Light Policy; dated 7/27/23 reads. Policy statement: It is the policy of this facility to ensure that there is prompt response to resident's call for assistance . 5. Be sure call lights are placed within reach of residents who can always use it. 2. On 09/05/2023 at 7:23AM during observation, R290 was observed lying in bed with her call light on the floor, out of R290's reach. At 7:30AM, R293 was observed lying in his bed with call light at the right corner of the head of R293's bed, out of R293's reach. At 7:31AM during observation with V6 (Registered Nurse), R290's and R293's call lights were observed out of their reach. On 09/05/2023 at 7:23AM, R290 said she needs something from the staff, but she cannot find her call light. R290 also said she cannot get up by herself and she needs help with moving around. On 09/05/2023 at 7:30AM, R293 stated he does not know where his call light is, and he needs help with repositioning and getting up. On 09/05/2023 at 7:31AM, V6 said call lights should always be within resident's reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 3 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 0558 On 09/06/2023 at 1:49PM, V2 (Director of Nursing) stated call lights should be within resident's reach. Level of Harm - Minimal harm or potential for actual harm R290's order review report dated 9/6/2023 indicated admission date of 08/21/2023 and diagnoses including unspecified psychosis and unspecified dementia. Occupational Therapy (OT) Evaluation and Plan of Treatment indicated start of care 8/23/2023, and functional skills assessment on transfers with current level of substantial/maximal assistance and on bed mobility with current level of partial/moderate assistance. Physical Therapy (PT) Evaluation and Plan of Treatment indicated start date of 8/22/2023, and functional mobility assessment on bed mobility with current level of partial/moderate to substantial/maximal assistance, and on transfers with current level of partial/moderate assistance to dependent. Residents Affected - Some R290's care plan initiated 08/04/2023 indicated R290 is at risk for falls and R290 requires assistance with ADLs (activities of daily living). R290's Minimum Data Set (MDS) Section C dated 08/24/2023 indicated Brief Interview for Mental Status (BIMS) score of 15. R293's care plan initiated 08/04/2023 indicate focus that R293 requires assistance with ADLs, R293 is at risk for falls, R293 is at risk for alteration of bowel and bladder functioning. R293 has potential for bruising, hemorrhage due to anticoagulant use and R293 is at risk for altered cardiovascular functioning with interventions including to keep call lights within reach when in bedroom or bathroom. R293's MDS Section C dated 08/18/2023 indicated BIMS score of 10. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 4 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were receiving routine range of motion exercises to maintain or prevent further loss of range of motion. This failure affected 5 residents (R18, R22, R56, R13, and R76) of 5 reviewed for range of motion in a total sample of 25. Findings include: 1. On 9-05-23 at 9:45 AM R56 said she is not receiving therapy services and said she is doing exercises for her right arm by herself without assistance from restorative nurse or CNA. On 9-05-23 at 9:25 AM R18 said she is no longer receiving therapy (due to insurance) and the staff is not helping her with exercises. On 9-05-23 at 8:39 AM, R22 said he has not received restorative therapy and is not currently receiving therapy services. On 9-06-23 at 12:04 PM, V2 (DON) said the previous company did not have a restorative program in place. Range of motion was provided during ADLs (dressing and bathing) by CNAs. On 9-07-23 at 10:57 AM, V27 (Director of Therapy Services) said currently there is a newly hired restorative nurse in training. V27 said there are no restorative aides that she is aware of. V27 and therapists would make resident recommendations to the nursing department to maintain patient level of mobility. V27 said R76 was not recommended for ROM services because there was no restorative program at that time. R56's Therapy Communication Record documents: Range of Motion/Movement: Active-assisted range of motion of upper extremities during ADLs, Passive range of motion of upper extremities during ADLs, Active-assisted range of motion of lower extremities during ADLs, Passive range of motion of lower extremities during ADLs. R18's Therapy Communication Record documents: Range of Motion/Movement: Active range of motion of lower extremities during ADLs. R22's Therapy Communication Record documents: Active range of motion of upper extremities during ADLs, Active-assisted range of motion of upper extremities during ADLs, Passive range of motion of upper extremities during ADLs, Active range of motion of lower extremities during ADLs, Active-assisted range of motion of lower extremities during ADLs, and Passive range of motion of lower extremities during ADLs. Surveyor reviewed resident records and asked for ROM (Restorative) Log however, facility was unable to provide documentation of ROM given to residents. 2. R76 is an [AGE] year-old resident whose diagnoses include frontal lobe and executive function deficit following non-traumatic intracerebral hemorrhage, other speech and language deficits following cerebral infarction (stroke), and other specified disorders of muscle. The Minimum Data Set indicates that R76 has an impairment of ROM (range of motion) of the upper and lower extremities on both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 5 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 0688 sides. Level of Harm - Minimal harm or potential for actual harm R76 received Physical Therapy in the facility from 6/23/23 to 7/21/23. The Physical Therapy Discharge Summary Recommendations indicate that a range of motion program was established and nursing f/u (follow-up) program for ROM referral was completed to enhance safety. Residents Affected - Some The facility did not provide any documentation that R76 had received ROM exercises after Physical Therapy was complete on 7/21/23. R13 is a [AGE] year-old resident whose diagnoses include end stage renal disease, unspecified symptoms and signs involving the musculoskeletal system, and chronic viral hepatitis C. The Minimum Data Set indicates that R13 has an impairment of ROM (range of motion) to both lower extremities. R13 received Physical Therapy from 4/29/23 to 7/3/23. The Physical Therapy Discharge Summary Recommendations indicate that a range of motion program was established and nursing f/u (follow-up) program for ROM referral was completed to enhance pt's (patient's) quality of life. A Therapy Communication dated 7/3/23 indicates active range of motion of upper extremities during ADLs (activities of daily living), active-assisted range of motion of upper extremities during ADLs, passive range of motion upper extremities during ADLs, active range of motion of lower extremities during ADLs, active-assisted range of motion of lower extremities during ADLs, passive range of motion lower extremities during ADLs. The facility did not provide any documentation that R13 received any ROM exercises after Physical Therapy was complete on 7/3/21. On 9/6/23 at 11:05 AM V7 (Assistant Director of Nursing) said, We are in the process of getting restorative up and running based on Physical Therapy recommendations. We are just providing range of motion and things like that. I'm not sure of the documentation. On 9/6/23 at 12:50 PM V2 (Director of Nursing) said that there is not any documentation of ROM exercises performed by the nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 6 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor a resident assessed as a high fall risk from having an unwitnessed fall from his bed. This failure affected 1 of 4 residents (R27) reviewed for falls. The facility failed to follow the Fall Policy by not conducting fall investigations or determining the root cause of fall incidents. This failure affected 3 of 4 (R18, R22, R27) residents reviewed for falls. The facility failed to follow fall care plan interventions by not using 2 staff members to provide care to resident in bed which resulted in resident falling out of bed and sustaining skin tears. This failure affected 1 resident (R1) of 3 residents reviewed for falls in a total sample of 25. Findings include: 1. On 9-7-23 at 1:20 PM, V1 (Administrator) said a fall investigation is to determine the cause of the fall and to help put interventions in place to prevent re-occurrences. V2 (DON) said there was no documentation of root cause analysis for R18, R22, and R27. On 9-6-23 at 11:11 AM, V7 (ADON) said she is unable to locate root cause analysis. The facility was unable to provide Fall Investigations and Root Cause Analyses for R18, R22, and R27. Fall Occurrence Policy (reviewed 7-17-23) documents: the falls coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 2. On 9-7-23 at 1:20 PM, V1 (Administrator) said a fall investigation is to determine the cause of the fall and to help put interventions in place to prevent re-occurrences. On 9-6-23 at 12:04 PM, V2 (DON) said R27 is not alert, oriented x 1-2, able to make simple needs known at times. V2 said R27 has very poor safety awareness due to inability to ambulate and over confidence. V2 said R27 has frequent behaviors of trying to get up from bed by himself without asking for help and does not use his call light. V2 said R27 is very high fall risk and has a history of falls. V2 said prior to R27's recent fall, R27 was moved closer to nursing station, had floor pad, had low bed in place, and had quarter rails in place. V2 said R27 requires frequent repositioning in bed. V2 said he is not aware of Root Cause Analysis for the 4 recent falls. V2 said R27's most recent fall risk management does not document the last time R27 was seen in bed. V2 said there was no documentation of root cause analysis On 9-6-23 at 11:11 AM, V7 (ADON) said alert, oriented x1, able to make simple needs known. V7 said R27 is confused with poor safety awareness. V7 said R27 thinks he can do more than he's capable of doing. V7 said R27 tries to get up by himself without calling for assistance. V7 said R27 is a high fall risk due to multiple falls and has a history falls. V7 said R27 requires frequent supervision every hour. V7 said R27 is placed in common area for observation and monitoring. V7 said when R27 is in his room, R27 should be observed every half hour to an hour. Prior to last fall, facility had scoop mattress, and low bed in place. In the most recent fall, R27 was observed laying on the right side of the floor next to bed. V7 said R27 said he was trying to go home. V7 said that R27's risk management did not mention the last time the nurse or CNA rounded on the resident. V7 said she is unable to locate the root cause analysis for 4 falls. V7 said R27 had an unwitnessed fall in his room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 7 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 without injury. V27 said she is unable to locate root cause analysis. Level of Harm - Minimal harm or potential for actual harm On 9-5-23 at 11:17 AM, V17 (CNA) said R27 is oriented to self and not able to make his needs known. V17 said R27 is confused and not directable. V17 said R27 is high a fall risk because he tries to get up from the bed by himself without asking for help. V17 said R27 cannot use a call light due to his confusion. R27 is impulsive and difficult to redirect. V17 said R27 has a history of falls and V17 has seen R27 try to get up by himself and redirect R27 however he is not directable. CNA said she will get him dressed and place R27 in the public area for monitoring. R27 requires frequent monitoring every 30 minutes. If R27 is having more impulsive behaviors. R27 requires frequent monitoring. The facility had low bed, floor pad on the floor, and frequent checks. R27 is placed in public view and activities. R27 had a room close to the nursing station. Floor pads, low bed, and frequent checks were added interventions. A lot of staff was aware of fall risk and would check on R27. CNA is unaware of injury related to falls. Residents Affected - Few On 9-5-23 at 12:28 PM, V18 (Social Services Coordinator) said he is not alert, not oriented, and unable to make his needs known. V18 said R27 has dementia. V18 said V27 has impaired safety awareness because R27 is confused and not aware of current surroundings. V18 said all residents are a fall risk. V18 said she is aware of R27 having a history of falls at the facility and she is not aware of any injury related to the falls. V18 said R27 requires more frequent attention because of his confusion. V18 said R27 had floor mats, low bed, and kept at nursing station for monitoring. V18 said floor pads were put in place after a previous fall. R27's MDS (ARD 8-13-23) documents: BIMS= resident is rarely/never understood. Bed Mobility (self) limited, (support) one-person assistance. Transfer (self) =extensive assistance, (support) =two+ person extensive assistance. Surface to surface transfer= Not steady, only able to stabilize with staff assistance. Diagnoses (not limited to:) non-Alzheimer dementia, anxiety, and depression. R27's Fall Risk Evaluations (dated 5-19-23, 7-9-23, 7-13-23, 8-22-23, and 8-24-23) documents R27 is a high risk for falls. R27's Fall Risk Management form dated 8-24-23 documents: Nursing Description: At approximately 2am writer called to room by CNA. Resident observed laying on his right side on the floor next to bed with pillow under head. Bed noted in lowest position. Resident description: Resident said, I was trying to go home. Immediate Action Taken: Resident AOx1-2 performing within normal baseline. Head to toe assessment completed no new injuries noted. While performing ROM to extremities resident made facial grimaces otherwise extremities WNL. Denies hitting his head. Vital signs BP 118/72, HR 86, T 97.0, R20, O2 95% RA. Resident transferred via mechanic lift x2 assist from floor to bed. ADON called and made aware. MD paged. (R27's) daughter called and made aware of patient to Hospital for evaluation. Fall Risk Management forms dated 8-22-23, 7-1323, and 7-9-23 were also reviewed. Most of these forms do not document any detailed time lines, investigative interviews, or root cause analysis. R27's Progress Note dated 8-24-23 documents: At approximately 2 am writer called to room by CNA resident observed laying on his right side on the floor next to bed with pillow under head. Bed noted in lowest position. Resident stated, I was trying to go home. Resident AOX1-2 performing within normal baseline. Head to toe assessment completed no new injuries noted. While performing ROM to extremities resident made facial grimaces otherwise extremities WNL. Denies hitting his head. Vitals obtained BP 118/72 HR 86 T 97.0 R 20 02 95% RA. Resident transferred via mechanical lift x2 assist from floor to bed. ADON called and made aware. MD paged. R27's daughter called and made aware of patient transfer to [NAME] Hospital for evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 8 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 Level of Harm - Minimal harm or potential for actual harm Surveyor asked Falls Nurse and Director of Nursing for Fall investigations and Root Cause Analyses and the facility could not provide Fall Investigations and Root Cause Analyses. The facility was unable to provide Fall Investigations and Root Cause Analyses for R18, R22, and R27. R27's Fall Care Plan documents: Frequent rounding (date initiated 7-12-23). Residents Affected - Few Fall Occurrence Policy (reviewed 7-17-23) documents: the falls coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 3. R1 is a [AGE] year-old resident whose diagnoses include generalized anxiety disorder, unspecified convulsions, and other specified disorders of muscle. On 9/6/23 at 3:55 PM V22 (CNA-Certified Nursing Assistant) said V22 went to change (R1). R1can turn in bed. V22 said, I asked him to turn to the right. He rolled out of bed to the floor. He kind of scraped his foot on the gastric tube pole. The nurse (V21-Registered Nurse) checked him, and we transferred him to bed with the (mechanical lift). I was changing him by myself. The Risk Management document completed by V21 on 5/29/23 indicates the assigned CNA was changing the incontinence pad and the resident rolled over. V21 tried to assist resident while falling, the resident slid on the floor but didn't hit his head. A Risk Management documented completed by V23 (LPN-Licensed Practical Nurse) on 8/19/23 indicates that V23 was notified by a CNA that while giving patient a bed bath patient turned over and rolled out of bed. On 9/6/23 at 4:00 PM V23 said the CNA was giving a bed bath. V23 said, the CNA came and told me that (R1) fell on the floor. Two other CNAs and I used the (mechanical lift) to put him back to bed. The wound care nurse (V32-LPN) assessed a skin tear on his right elbow. I called 911 and sent him to the hospital. R1 did not say that he had been pushed. R1 said, Get me off the floor. I don't know how many CNAs were bathing him. An email from V36 indicates I (V36) was giving a bed bath to (R1). V36 said, As I was done with the bath and asked (R1) to roll over so that I could put his brief on. As he rolled over (R1) stated is this good. I replied yes. As I turned to grab the brief off the nightstand (R1) was scooting over again and I didn't know. As I turned back around (R1) was on the floor. I then called the nurse for and another CNA to help assist (R1) off the floor. I work with (R1) all the time so I know how to care for him. I didn't push him. I always ask him to roll for me knowing how anxious he be. On 9/7/23 at 9:23 AM V36 was called. She identified herself. The call was disconnected when I said that I wanted to ask some questions about R1. Repeated calls were not answered. On 9/7/23 at 12:45 PM V1 (Administrator) reviewed the Risk Management document dated 8/19/23 and said, I would say that there was one CNA with (R1) when he fell. A Fall Risk Evaluation completed 5/29/23 indicates that R1 scored 11 which means that he is a High Fall Risk. The Care Plan for R1 was updated on 6/1/23 and indicates use two people to change and reposition me. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 9 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide specialized care needs according to professional standards for residents on oxygen therapy for three of three residents (R293, R292, R61) reviewed for oxygen in a sample of 25. Residents Affected - Few Findings include: On 09/05/2023 between 7:33AM to 7:40AM during observation with V6 (Registered Nurse), R293's and R292's room/door did not have any sign or indication that R293 and R292 were on oxygen. Upon entrance, R293 and R292 were observed connected to oxygen concentrator via undated nasal cannula. At 8:15AM during observation with V7 (Assistant Director of Nursing), R61's room/door did not have any sign or indication that R61 was on oxygen. Upon entering, R61 was observed connected to oxygen concentrator via undated nasal cannula. On 09/05/2023 at 7:40AM, V6 stated that there should be sign by the door indicating resident is on oxygen and the oxygen cannula should be dated each time it is being changed. On 09/05/2023 at 8:15AM, V7 said that a sign by the door should indicate the resident is on oxygen and the nasal cannula should be dated every time it is changed. R61's order review report dated 9/6/2023 indicated admission date of 08/08/2023, diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen, and order for oxygen continuous 5 liters per minute (L/min) via nasal cannula every shift with order date of 08/10/2023. R292's order review report dated 9/6/2023 indicated admission date 09/01/2023, diagnoses including chronic obstructive pulmonary disease, and order for oxygen (O2) 3 liters per minute via nasal cannula every shift with order date of 09/02/2023. R293's order review report dated 9/6/2023 indicated admission date 08/04/2023, diagnoses including chronic obstructive pulmonary disease, and order for oxygen continuous 4 liters per minute (L/min) via nasal cannula every shift with order date of 08/21/2023. Facility Policy: Title: Oxygen Therapy and Administration Revised: 07/28/2023 Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Procedure: Date your equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 10 of 11 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 145893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow its infection control policy on hand hygiene for one of six residents (R61) reviewed for infection control in a sample of 25 residents. Residents Affected - Few Findings include: On 9/5/22 at 1:00PM, during medication administration for R61, V6 (Registered Nurse) was observed picking up a garbage can per R61's request to bring it closer to R61. V6 then proceeded to spike an IV (intravenous) bag without changing gloves or performing hand hygiene. On 9/6/23 at 135PM, V6 stated, I should have washed my hands to prevent cross contamination. On 9/6/23 at V2 (Director of Nursing) stated that hand hygiene should be performed after touching a dirty surface and before providing care to residents. On 9/7/23 at 1:30 PM, V11 (Infection Prevention) stated employees are expected to change gloves or perform hand hygiene after encountering a contaminated surface and before providing care to residents. A physician order sheet dated 8/8/2023 indicates R61 was admitted on [DATE] and has a diagnosis of urinary tract infection. A care plan initiated 8/8/23 indicates R61 has potential for infection related to right upper extremities single lumen PICC (Peripheral Inserted Central Catheter) line, R61 is on Enhance Barrier Precaution dated 8/25/23. Change gown and gloves before caring for the next resident. Physician order dated 8/9/23 indicates; Ceftriaxone sodium injection solution Reconstituted 2GM. Use 2 gram intravenously one time a day for Discitis until 9/30/23. Facility policy dated 6/1/23 titled. Infection Prevention and Control. Policy Statement: The facility has established a policy, record investigation, control, test and prevent infection in the facility Procedures: 17. Hand hygiene will be performed by staff before and after direct patient contact and after situation that necessitates hand hygiene. Alcohol-based hand rubs or hand washing x20 seconds will be used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 11 of 11