Health inspection·June 18, 2025

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. Page 1 of 2 145893 145893 06/18/2025 Harmony Palos 11860 Southwest Highway Palos Heights, IL 60463

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. 145893 Page 2 of 2