Harmony Palos

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff follow professional standards of practice when administering medication by failing to administer medication before documenting, failed to correctly document refused medication and failed to notify attending physician that a resident was refusing a particular medication. This failure affected one (R3) of five residents reviewed for nursing services.

Inspectors wroteBased on interview and record review, the facility failed to protect resident's right to be free from abuse. This deficient practice affects one resident (R6) of three residents reviewed for abuse. This failure resulted in R6 having right leg shin bruising/hematoma. Findings Include:Facility Reported Incident to State Agency dated 3/22/26, reads in part: On 3/22/26 @ 8pm, R6 reported that V15 (CNA) kicked her in her leg and pulled her hair. V15 was removed from the building immediately. Notified attending physician, and emergency contact. Police Department was called and is in route. R6 is an [AGE] year-old female resident with diagnoses of Metabolic Encephalopathy, and Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. On 5/6/26 at 9:30AM, observed R6 in bed watching television. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement fall care plan interventions for fall-risk residents. This applies to 2 of 3 residents (R4 and R8) who were reviewed for falls and injuries in a sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the fall care plan interventions in place for at-risk fall residents. This applies to 3 of 3 residents reviewed for falls in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to acquire and administer prescription medications to residents. This applies to 1 of 3 residents reviewed for pharmacy services in a sample of 6The

Inspectors wroteBased on interview and record review, the facility failed to order and initiate contact isolation precautions for a resident (R4) while the resident was being treated for scabies for one out of three reviewed for infection control in a total sample of eight. Findings Include: R4 is a [AGE] year-old with the following diagnosis: dementia, Alzheimer's disease, and lung cancer. R4 was unable to answer questions due to mental status. On 3/7/26 at 1:24PM, V3 (CNA/Certified Nurses Assistant) stated R4 had a rash on the arms, chest, and back about a couple months ago. V3 reported residents that are being treated for scabies are put on isolation immediately, so they don't spread it to other residents or staff. V3 stated V3 was not aware R4 had been treated for scabies. V3 denied ever seeing R4 on isolation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (R1) reviewed for accidents was free from accident hazards and received adequate supervision and assistive devices to prevent an avoidable fall. Specifically, the facility failed to ensure an agency CNA (V3) was oriented to R1's high fall risk status. This failure resulted in R1 sustaining a displaced humerus fracture, head laceration with active bleeding requiring sterile-strips, and facial contusions. R1 is an alert and oriented predominantly Polish-speaking [AGE] year old with diagnoses listed in part but not limited to type II Diabetes, Fracture of the Upper End of Right Humerus, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension, Anxiety Disorder and History of Falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the established comprehensive care plan for 1 of 3 residents (R1) to ensure safety during bed mobility and ADL (Activities of Daily Living) care and failed to communicate the resident's fall risk status. Specifically, facility staff failed to provide the required level of assistance and supervision mandated by the care plan, which led to a fall resulting in significant injury of a Humerus Fracture. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 3 residents (R1) received care from staff with documented competency and training. Specifically, the facility assigned an agency CNA to provide direct care for R1 without first validating that the staff member possessed the necessary clinical skills or had been oriented to R1's specific safety needs, including fall risk status and required levels of assistance. As a result, the facility failed to ensure that R1 was provided care by a staff member with verified qualifications to perform the assigned duties. R1 is an alert and oriented predominantly Polish-speaking [AGE] year old with diagnoses listed in part but not limited to type II Diabetes, Fracture of the upper end of Right Humerus, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension, Anxiety Disorder and History of Falls. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff turn/reposition residents safely, failed to ensure that staff report resident falls, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, failed to provide supervision, and/or failed to ensure that equipment was functioning properly for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1's (5/9/25) fall with sustained right acute intertrochanteric femoral neck fracture and pain rated 5/10.

Inspectors wroteBased upon record review and interview the facility failed to revise a comprehensive care plan for three of three residents (R1, R2, R3) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to implement effective fall interventions and supervision for a dependent resident assessed as a high risk for falls. This failure affected one resident (R2) of four residents reviewed for falls. This failure resulted in (R2) having a fall, being sent out to the emergency room, and sustaining a laceration to right eyebrow requiring 3 sutures.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for care planning and fall prevention by not implementing previously established fall interventions based on all available information for a resident readmitted to the facility with a history of repeated falls and by not implementing personalized fall interventions or ensuring all available sources of information were utilized to identify and implement effective fall interventions for a resident who was admitted to the facility after being hospitalized from a fall that resulted in multiple significant injuries. This failure applies to two of four residents (R7 and R56) reviewed for falls and resulted in R56 experiencing a fall that resulted in a thigh bone fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not using hand hygiene, when necessary, not sanitizing surfaces after cleaning them, not ensuring appliances were adequately dried or free of surface contamination after cleaning and before use, and not ensuring hair restraints were worn properly. This failure applies to all 96 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedures for comprehensive care planning by not ensuring care plans, and personalized care planning interventions were implemented as needed based on grievances, resident's past medical history, and comprehensive assessments. This failure applies to four of four residents (R7, R16, R45, and R56) reviewed for care planning.

Inspectors wroteBased on observation and interview the facility failed to follow their policy to ensure multidose vials of insulin were dated when vials were first accessed for two residents (R14 and R5) and failed to safely dispose of seven expired bottles of house stock medications. This failure has the potential to affect 38 residents residing on the second floor.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to implement the use of personal protective equipment during provision of care on residents in isolation rooms; failed to change soiled gloves during ADL (activities of daily living) care; and failed to prevent contamination of urinary catheter and bag by keeping it off the floor for four (R15, R71, R101 and R112) of four residents in the sample of 46 reviewed for infection control.

Inspectors wroteBased on observation, interviews and record review, the facility failed to assess and evaluate a resident for self-administration of inhalers and eyedrops; and failed to obtain physician's order for eyedrops for one (R10) of one resident in the sample of 46 reviewed for medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policies for restorative nursing program services by not ensuring a resident received the necessary treatment and services to prevent further decline in physical functioning for a resident with a contracture. This failure applies to one of one resident (R45) reviewed for rehab and therapy services.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place and failed to ensure dressing changes were completed for a resident with pressure ulcers for 2 of 3 residents (R3, R4) reviewed for pressure ulcers in the sample of 12.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and value the resident's private space for three of five residents (R290, R292, R293) observed for resident's rights in a sample of 25.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to follow the Abuse and Neglect Policy by not reporting a suspicious arm bruise for 1 of 3 residents (R27) reviewed for injury of unknown origin/abuse in a total sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call lights in reach for four residents (R16, R24, R48, R75) of seven reviewed for accommodation of needs in the sample of 21.

Inspectors wrote2. On 5/24/22 at 12:05 PM the cart for PPE (personal protective equipment) for R78, R79, and R131 do not contain any gloves. On 5/25/22 at 9:45 AM the cart for PPE for R131 does not contain any gloves. On 5/24/22 at 1:10 PM V14 (Central Supply Clerk) said, I stock the cart when I bring it up and the CNAs (Certified Nursing Assistants) are responsible to replace items from the clean utility room. On 5/25/22 at 10:00 AM V15 (Certified Nursing Assistant) said, I have put some gowns in them (PPE carts). I guess everybody should replace stuff. They didn't give it to us as a specific CNA duty. On 5/25/22 at 12:21 PM V2 (Director of Nursing) said, residents who have not completed the Covid vaccine are placed on droplet and contact precautions for ten days. R78, R79, and R131 are on droplet and contact precautions. There is no policy for stocking PPE carts. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy by failing to provide catheter dignity bags to two residents R15 and R27 reviewed for catheters in a sample of 21 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to properly administer medications as per physician orders and in accordance with professional standards of clinical practice, for one of one resident (R17) in a sample of 21 reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal hygiene and grooming, including incontinence care to residents who need total care in a timely manner. This deficiency affects all three (R24, R57 and R60) residents in a sample of 21 reviewed for Activity of Daily Living (ADL) provided for dependent residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide treatment and care in accordance with professional standards and their care plan for residents' who have a Peripheral Inserted Central Catheter (PICC), severe contractures on upper and lower extremities and a venous stasis ulcer. This deficiency affects two (R24 and R57) of three residents reviewed for Quality of Care.

Inspectors wroteBased on interview and record review the facility failed to designate a qualified Infection Preventionist (IP) who had completed a specialized training course to be responsible for the facility's Infection prevention and Control Program necessary for the Covid-19 survey protocol. This failure has the potential to affect all residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a bed that is in safe operating condition to a resident. This deficiency affects one (R60) of three residents reviewed for bed safe operating condition.