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
interview and record review, the facility failed to follow their Incident Reporting Policy. Facility failed to timely
report (within 24 hours) a major injury from a known incident to IDPH (Illinois Department of Public Health).
This deficient practice affects one resident (R1) of three residents reviewed for incident/accident.
Findings Include:
R1 is a [AGE] year old female resident, with diagnosis of but not limited to: Congestive Heart Failure,
Pressure Ulcer Sacral Stage 3, Chronic Kidney Disease, Seizures, Lymphedema, and Pulmonary
Hypertension. R1 has a BIMS of 8 (Moderate Cognitive Impairment).
Facility Provided Initial Report to IDPH of this major injury on 5/13/25, reads in part: CNA (Certified Nursing
Assistant) towards the end of providing peri-care to R1 in bed, on the last time that CNA turned R1 towards
her, CNA inadvertently overturned resident's right leg. In the CNA's attempt to prevent R1 from rolling out of
bed, CNA turned R1's leg back to bed preventing a fall. After peri care. R1 complained of right hip pain.
Pain medication administered and provided relief. Attending physician who was in the building at the time
was informed and gave orders for x-ray to the right femur and right knee. X-ray showed acute right
intertrochanteric femoral neck fracture. Family was informed and advised for resident to be sent out to
hospital, but family refused.
Final report to IDPH, dated 5/17/25 reads in part: CNA inadvertently overturned resident's right leg. This
resulted in R1 falling out of the bed and on to the floor. Currently R1 remains in the facility and pain
management effective. Family decided for conservative management and non-surgical intervention due to
R1's age. R1's care plan was updated to include assistive device in bed to assist resident with turning and
repositioning.
X-ray result dated 5/9/25 reported at 19:00, and shows that Right femur has a Lucency across the
intertrochanteric femoral neck and lesser trochanter concerning for an acute intertrochanteric femoral neck
fracture. Consider dedicated frontal and frog-leg lateral right hip radiographs versus a CT.
On 6/17/25 at 11:10AM, V2 (DON) stated that on 5/9/25 V2 received a report from PT saying R1 is
complaining of leg pain. V2 questioned staff on 5/9/25 and per CNA the resident rolled out of the bed half
way. Right leg and the head was out of the bed. V2 also stated that on 5/9/25 Attending Physician ordered
X-ray and then came back with fracture. V2 stated that V2 was not made aware of Fracture result until
5/13/25, and it was then reported to IDPH that day, which started V2's investigation.
(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
06/18/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
V2 stated that a fall incident or any known incident with major injury needs to be reported within 24 hours of
finding the negative finding of x-ray result.
Incident Reporting Policy with a revised date of 1/3/25, reads in part: It is the policy to ensure that all
reportable incidents as stipulated in the Section 300.690 state regulation, are reported to the state agency.
Residents Affected - Few
Any serious injury sustained by a resident that is not expected outcome of the disease process will be
reported to IDPH Regional Office. As per IDPH clarification physical harm: does not include skin tear or
bruise of something that can be covered by a band aid. Physical harm includes a fracture or blood flor not
stopped by band aid or hospital treatment involves more than diagnostic evaluation. Therefore post ER
(Emergency Room) evaluation that includes diagnostic evaluation only with subsequent findings of No
injury do not have to be reported.
The facility shall, by fax, phone, email, or directly through the IDPH Portal notify the Regulation Office within
24 hours after each reportable incident or accident.
The facility shall send a narrative summary of each reportable accident or incident to the Department within
seven days after the occurrence.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145893
If continuation sheet
Page 2 of 2
