Health inspection·March 11, 2024

F 0686 Level of Harm - Minimal harm or potential for actual harm R3's October 2022 eTAR (electronic Treatment Administration Record) showed Dressing to coccyx; Remove all packed calcium alginate with silver, skin prep peri wound, pack with calcium alginate with silver, cover with foam dressing post normal saline cleanse every day . This treatment was not documented as completed on 10/3, 10/7, 10/13, 10/17, 10/18, 10/20, 10/21, 10/25, 10/26, 10/27, and 10/31. This record showed only 11 of 31 scheduled daily dressing changes were not completed. Residents Affected - Few R3's November 2022 eTAR showed the same daily dressing change to R3's coccyx was not completed 11/2, 11/4, 11/11, 11/14, 11/16, 11/18, 11/23, 11/25, 11/28, 11/30. This record showed 10 of 30 scheduled dressing changes were not completed. R3's December 2022 eTAR showed the same daily dressing change to R3's coccyx was not completed 12/1 and 12/2. This record showed 2 of 5 scheduled dressing changes were not completed. R3's 12/5/22 nursing note showed, Patient was sent to [the acute care hospital] due to increased wound drainage and blood noted. Wound itself and tissue around it has also changed since I last had her maybe a week. Brother [V20] was also concerned about her wound and how much pain she was in. [Physician] was notified and gave orders to send out. R3's 12/6/22 nursing note showed, Resident was admitted to [the acute care hospital] for wound review. The facility's policy and procedure titled Skin Care Regimen and Treatment Formulary with review date of 1/24/24 showed, . Policy Statement: It is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for residents with skin breakdown Pressure Injuries . Deep Tissue Injury: . Relieve pressure . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 2 of 7 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 03/11/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure enhanced foods were provided as ordered and weights were obtained as ordered for a resident with weight loss for 2 of 3 residents (R1, R2) reviewed for weight loss in the sample of 12. Residents Affected - Few The findings include: 1.R2's computerized profile printed on 3/9/24 shows diagnosis to include aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, morbid obesity, and atrial fibrillation. R2's Facility assessment dated [DATE] showed R2 was dependent on staff for hygiene, toileting, bathing, and dressing. This assessment showed R2 was incontinent of bowel and bladder, and dependent on staff for bed mobility. This assessment showed R2's weight was 267 pounds, and R2 had no identified weight loss. On 3/9/24 at 9:42AM, R2 was resting in bed with the head of her bed elevated. R2 had a water pitcher with straw on the right side of her bedside table. There were no other food or drink items on her table. On 3/9/24 at 12:24PM, R2 was in bed with the head of bed elevated. R2 had a Styrofoam tray with a gyro (meat and pita, onions, and sauce) and French fries in front of her on her over the bed table. Less than 1/2 of the gyro was present on her tray. R2 was eating fries. R2 did not have a facility tray of food in her room. No health shakes or enhanced foods were in her room. At 12:30PM, V19, (R2's husband) said he brought R2 her lunch today. V19 said R2 needs help eating, and you need to make sure everything is open for her. V19 said they must make sure she eats; she had a 20 pound weight loss. R2's Dietary Evaluation dated 11/15/23 shows R2 was NPO (nothing by mouth) and received enteral feedings (gastrostomy tube feeding) of Jevity 1.5 bolus 300ML 4 times a day. This assessment showed R2 was 268 pounds, and her BMI was 42. R2's Progress Noted dated 1/15/24 shows, MD/NP present at resident bedside, MD attempted reinsertion of G-but but was unsuccessful, MD/NP communicated in regard to resident G-tube and decided to keep it out with reevaluation scheduled next week Wed as they will be monitoring resident for I&O and see how Pt will be in 1 week without G-tube . R2's 1/22/24 Physician Progress note shows, After G tube removal-pt doing well. No weight loss noted. Pt tolerating food well . R2's Physician Progress noted dated 2/12/24 shows, Follow up, significant weight loss/other s/s concerning food and fluid intake .Patient is non-verbal due to aphasia. Patients nodding head to some questions .seen today for significant weight loss. Pt's weight dropped from 271.4lbs on 1/3/24 to 251.8lbs on 2/5/24. G tube was pulled- patient is on PO (oral) diet. Very good appetite as per staff. Pt's husband and pt okay with weight loss . This progress note shows #1 Other s/s concerning food and fluid intake/weight loss - continue current diet along with health shakes. Re-weigh in 2 weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 3 of 7 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 03/11/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's Dietary Evaluation dated 2/26/24 shows R2's most current weight was 250 pounds on 2/24/24 and R2 had a loss of 5% or more in the last month or 10% loss or more in last 6 months. This assessment shows R2 was not on a prescribed weight-loss regimen. R2's Dietary Evaluation showed R2 is currently receiving a General Dysphasia Mechanically Altered Level 2 diet. appetite noted to be 50-75% of meals .Patient current weight 250.0#, BMI 39.2 .Patient weight ranges from 250-273#. Patient has a loss of 7.9% since admitted back from hospital. Patient G-tube was pulled out not reinserted .will recommend adding Enhanced foods to diet to help maintain current weight. Will continue to monitor patient appetite . This assessment showed, intervene with nutritional support for your patients at risk of malnutrition: Recommend adding Enhanced Foods. R2's Nutrition care plan dated 2/24/24 shows readmitted resident with weight loss noted. On General Dysphagia, mechanically Altered Level 2, enhanced foods added for weight management. This care plan had an intervention to provide diet and supplements as ordered .Enhanced foods added. R2's medical record shows her weight on 1/3/24 was 271.4 lbs. (mechanical lift). On 2/5/24 R2's weight was 251.8 lbs. (mechanical lift)- 5% change [comparison weight 1/3/24, 271.4 lbs., -7.2%, -19.6 lbs.]. R2's medical record showed her weight on 3/1/24 was 249 lbs.- 7.5% change (comparison weight 1/3/24, 271.4 lbs., -8.3 %, -22.4 lbs.) R2's Physician Orders show a General Diet, Dysphagia Mechanically Altered (level 2) texture, think liquids consistency, Enhanced Foods. Order Start Date 2/26/24. On 3/9/24 at 11:15PM, V21 (Licensed Practical Nurse- LPN) said R2 needs assistance with eating. R2 used to eat by herself but went to the hospital with the flu and now needs help eating. V21 said the CNA's (certified nurse assistants) help her and if they can't the nurse will. V21 said R2 used to have tube feedings. V21 said R2 had a weight loss of 20 pounds, and she notified the doctor and speech therapy. R2 said the doctor increased her health shakes, and her husband brings in food for her. On 3/9/24 at 12:37PM, V6 (CNA) said R2 is eating better by herself, but they offer to help her if she needs it. V6 said R2 does not get any supplements (health shakes etc.). On 3/9/24 at 3:30PM, V10 (Registered Dietician) said R2 has enhanced foods added to her meals. V10 said, Enhanced foods are super potatoes, puddings, soup, etc. They have extra calories and protein and are added to each meal. Enhanced foods are part of her diet order, and the kitchen would add the foods. V10 said R2 had a big weight loss. V10 said R2's weight loss is a concern initially, despite her BMI, which is why she added enhanced foods. V10 said even if R2's husband brings in food, they should still be providing her a tray. V10 said, it is up to R2 what she chooses to eat. On 3/9/24 at 3:50PM, V12 (Dietary Tech) said if a resident had an order for enhanced foods, it would be printed on their diet ticket. V12 looked at R2's diet ticket and said she did not have an order for enhanced foods, she was just on a general mechanical soft diet. V12 looked at R2's breakfast ticket and said she did not have enhanced foods for breakfast today. V12 looked at R2's diet order in the computer and said R2 was on a general mechanical soft diet. V12 said R2 was supposed to have enhanced foods according to the order. V12 said R2 should have had super cereal for breakfast and super mashed potatoes for lunch. V12 said enhanced foods are used for extra calories and to help a resident gain weight. They are provided to residents who are losing weight. V12 said health shakes come from dietary if there is an order for the resident to have them. V12 said there is no order for R2 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 4 of 7 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 03/11/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have health shakes. R2's Diet Ticket printed on 3/9/24, by V12 does not show enhanced foods or health shakes for breakfast, lunch, or supper meals. On 3/9/24 at 4:01PM, V17 (Registered Nurse- RN) reviewed R2's orders. V17 said R2 did not have any health shakes, or enhanced foods ordered. There was nothing entered on her MAR (Medication Administration Record), and health shakes would be on the MAR if it was ordered. On 3/9/24 at 4:05PM, V18 (CNA) said R2 did not have any health shakes that she was aware of. V18 said the health shakes would come on her tray if she was getting them. They would come from dietary or the nurse. On 3/9/24 at 4:25PM, V8 (Regional Nurse Consultant) reviewed R2's record and the Physician Progress note dated 2/12/24. V8 said if the physician enters health shakes in the progress notes, they should be entered as an order. If nursing, sees the progress note they should clarify with the doctor or dietician. V8 said there was an order entered on 2/26/24 for R2 to have enhanced foods. A facility policy was requested for enhanced foods and nutritional supplements. None was provided. 2. R1's Physician Orders Set printed on 3/9/24 shows diagnoses to include paraplegia, absence of left leg above the knee, paralytic milieus, chronic obstructive pulmonary disease, quadriplegia, antisocial personality disorder, anxiety disorder, and major depressive disorder. R1's facility assessment dated [DATE] shows he is cognitively intact and is dependent on staff for eating, hygiene, and activities of daily living. This assessment shows his weight was 213 lbs. with no identified weight loss. R1's care plan initiated 12/20/23 shows [R1] is at risk for alteration in nutritional status related to left AKA, Paraplegia, BMI (over wt. status). Noted refused meal at times due to [R1's] unsatisfaction with food in the facility, however [R1] orders outside food and keeps snacks inside of his room. This care plan has an intervention dated 12/20/23: obtain weight as ordered. R1's weight record shows his weight on 1/9/24 was 213. 4 pounds (mechanical lift) R1's Physician Orders show an order with start date of 2/1/24 for: weight upon admission/readmission, weekly x 4, then monthly every day shift starting on the 1st and ending on the 7th every month monthly. R1's weight record on 2/9/24 shows 195 lbs. (mechanical lift). -5% change [comparison weight 1/22/24, 213.0 lbs., -8.5%, -18 lbs. The next weight obtained for R1 was 3/8/24 (almost 1 month later) recorded as 196 lbs. (mechanical lift). There were no weekly weights documented. On 3/9/24 at 3:10PM, V4 (Assistant Director of Nursing) said weights should be obtained as ordered. If they are unable to get a weight, or if a resident refuses it should be documented in the record. On 3/9/24 at 3:30PM, V10 said if a doctor orders weekly weights, she would expect them to be done. V10 said she would be seeing R1 this month for his weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 5 of 7 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 03/11/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm On 3/9/24 at 3:46PM, V9 (Restorative Nurse) said restorative staff are responsible for monthly weights. If there are orders for more frequent weights, like weekly weights, the nurses on the floor would do those. V9 said the weight order will be on the MAR and once entered it would flow over to the weight tab in the computer. Residents Affected - Few A facility policy was requested on weight loss/ obtaining weights, and none was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 6 of 7 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 03/11/2024 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 provide incontinence care in a manner to prevent cross-contamination for 1 of 3 residents (R2) reviewed for activities of daily living in the sample of 12. Residents Affected - Few The findings include: R2's computerized profile printed on 3/9/24 shows diagnosis to include aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, morbid obesity, and atrial fibrillation. R2's Facility assessment dated [DATE] showed R2 was dependent on staff for hygiene, toileting, bathing, and dressing. This assessment showed R2 was incontinent of bowel and bladder, and dependent on staff for bed mobility. On 3/9/24 at 1:23PM, V6 (Certified Nursing Assistant - CNA) removed R2's blankets and unfastened R2's incontinence brief. V6 rolled R2 over on her left side. R2 was incontinent of urine and stool. V6 tucked the soiled incontinence brief under R2 and used wipes to clean R2 of stool. V6 then applied petroleum jelly to R2's bottom. Without changing her gloves, V6 rolled R2 on her back and applied petroleum jelly to R2's vaginal area and inner thighs. With the same gloves on, V6 fastened the right side of R2's clean brief. Without changing her gloves, V6 rolled R2 onto her right side. Without providing any cleansing (to R2's left buttocks), V6 removed the soiled incontinence brief, and pulled the clean one through. V6 fastened the left side of the brief, and balled up the soiled brief and threw it in the garbage. V6 then removed her gloves and sanitized her hands. On 3/9/24 at 1:30PM, V5 (Registered Nurse) said gloves should be changed during peri-care if they are soiled. On 3/9/24 at 3:10 PM, V4 (Assistant Director of Nursing) said gloves should be changed during incontinence care if they are visibly soiled. V4 said petroleum jelly should be applied to the vaginal area first, then the buttocks. Cleaning should be done front to back. Clean gloves should be used after applying the petroleum jelly, before touching clean items. Thorough peri-care should be given, including cleaning both sides of a resident's bottom. The facility policy Incontinent and Perineal Care revised 7/28/23 shows It is the policy of the facility to provide Perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. 5. Maintain clean techniques. 8. Remove gloves and dispose to designated plastic bag. Wash hands. 9. Put on new set of clean gloves to put on clean briefs, incontinent pads, to make resident comfortable, groom, and change clothing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145893 If continuation sheet Page 7 of 7