Inspection·September 27, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure medical records for one resident are complete and accurately documented by containing accurate and complete restorative assessments and interventions to address care plan needs. This affected one of three residents (R1) reviewed for medical records. The findings include: R1's diagnosis include, but are not limited to Vertebra Fracture, Cognitive Communication Deficit, Unspecified Symptoms and Signs Involving the Nervous System, History of Falling, Dementia, Depression, Anxiety, and Osteoarthritis. Incident report provided to IDPH states on [DATE] R1 complained of pain to the right shoulder. X-rays were obtained with findings of acute appearing clavicle fracture. R1 was sent for evaluation to the hospital on [DATE] and returned the same day to the facility. R1 was a hospice patient and died on [DATE]. On [DATE] at 12:48PM V2, Restorative CNA, said R1 was on a turning and repositioning program. V2 said R1 can turn but needed 2 person assistance turning. There was no documentation of this program in the records. On [DATE] at 2:07PM V7, CNA, said it was hard for R1 to turn on the right, she was about to cry. V7 said this was something new. V7 said, I don't remember if the nurses knew about it. I had R1 10-15 times. There was no documentation of this in R1's chart. On [DATE] at 2:15PM V8, CNA, said R1 was afraid to turn because she feared falling out of bed. V8 said before [DATE] R1 was 1 person assist for turning. On [DATE] at 2:30PM V3, Director of Nursing, said there is no risk management (incident report) for R1's injury. V3 said, I was told the IDPH reportable serves as the documentation. The surveyor asked how someone would know the resident's status regarding R1 new injury. V3 responded, We would know something happened based on the IDPH report and any x-rays. V3 said the IDPH reportable and risk watch (incident reports) are not part of the resident chart. V3 said it would be very important for providers to know if a fall or incident occurred. On [DATE] at 10:17AM V3 said, We do a root cause analysis on everyone. We have a separate binder for that. V3 said the purpose of the root cause analysis is to analyze the situation and determine if something can be done differently to prevent event from happening again. The surveyor reviewed R1's incident report with V3. V3 said R1 had some blood under his nails and some dried abrasions on his knee. V3 said we did an incident report on R1 in case R1 fell or complications occur later. The (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: 145893 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 09/27/2024 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)