Harmony Park Ridge

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with and received adequate fluid intake. This failure applied to four (R1, R4, R6, and R10) of four residents reviewed for hydration. Findings Include: The facility census dated 6/1/2026 shows there are currently 84 residents residing on the second floor who receive fluids by mouth. R10 is a [AGE] year-old female admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to rheumatoid arthritis, Alzheimer's, Crohn's, hypothyroidism, hypertension, dementia, dysphagia, atrial fibrillation, and depression. On the (MDS) Minimal Data Set assessment of 3/3/2026, section C1000(Cognitive Skills for Daily Decision Making) indicates severe cognitive impairment. On MDS of 3/3/2026 on section GG, Eating Ability, the resident requires partial/moderate assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a properly sized mattress to meet the needs of a tall resident, resulting in the resident's foot extending beyond the mattress, affecting comfort and dignity. Findings Includes: R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder status post suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, decubitus sacral ulcer, and colostomy. On the (MDS) Minimal Data Set assessment of 2/12/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On MDS of 2/12/2026, GG section R1 is dependent for personal hygiene and toileting hygiene. The helper does all the effort. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet the resident's need to have two staff members assist while being provided with incontinence care, as per the resident's assessed needs. This failure applied to one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while being provided incontinence care that resulted in a left knee skin tear and right shoulder pain. Findings Includes:R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder status post suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, decubitus sacral ulcer, and colostomy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary services and treatment were provided to prevent the development and/or worsening of pressure injuries for one (R2) of three residents reviewed for pressure ulcers. This failure resulted in R2 developing a Stage 3 pressure ulcer to the left buttock and a Stage 4 pressure ulcer to the right buttock while residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and implement appropriate interventions for one (R1) of three sampled residents reviewed for accidents and supervision who had severe cognitive impairment and was assessed as high risk for elopement. This failure resulted in R1 being sent to an outside medical appointment without an escort, leaving the medical building unsupervised, and being found confused and wandering in the street.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician order in using oxygen for resident who has respiratory disorder. This deficiency affects two (R2 and R3) of three residents reviewed for Respiratory/oxygen management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were served meals at a safe, appetizing temperature by not checking the food temperature before serving. This applies to all 121 residents consuming food through the dietary service.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Medication Storage, Labeling, and Disposal Policy. The facility failed to ensure medications will be stored in locked storage area. This failure has the capacity to affect 19 residents (reviewed for medications) in a total sample of 29. On 12/09/2025 at 12:08 PM, during rounds on the unit, observed medication cart in unit A, first floor, to be unlocked, third drawer opened halfway, with no authorized staff in the hallway. The medication cart was facing in the opposite direction that V7 (Registered Nurse/RN) was in. On 12/09/2025 at 12:12 PM, V7 (Registered Nurse) walked out of a resident's room, noticed the cart was left unlocked and third drawer open, proceeded to turn the cart the opposite direction. V7 (RN) stated the medication cart should have been fully closed and locked, for safety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Call Light Policy. The facility failed to ensure call lights are placed within reach of residents who are able to use it at all times. This deficient practice affects 2 residents (R68 and R52) of 4 residents reviewed for accommodation of needs in a total sample of 29 residents. On 12/09/2025 at 8:13AM Observed R68 and R52 in the same room, each asleep in their assigned beds. The privacy curtain was fully extended out in between R68 and R52. Observed R68's call light attached and clipped high, in the middle of the curtain that was extended all the way to R68's foot bed frame, not within reach of R68. R52's call light was observed under R52's bed, on the floor close to the foot of the bed, not visible to R52. Both R68 and R52's call light string was attached and connected to the call light system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their abuse policy by not protecting a resident from employee-to-resident abuse. This failure resulted in R85 sustaining redness, mild swelling, and facial bruising. This affected 1 resident of 3 reviewed for (Employee-to-Resident) Abuse in a total sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure specialty mattress devices were on the correct weight setting for residents who are high risk in developing pressure injuries. This failure has the potential to affect two resident (R27 and R69)) out of three residents reviewed for pressure injury prevention and treatment in a final sample of 29 residents. Findings Include:R69:On 12/9/25 at 8:00AM, observed R69 in bed, asleep using specialized mattress. Low Air loss mattress is set to 4 (250 lbs.)On 12/9/25 ay 8:07AM, confirmed with V3 (Registered Nurse) R69's Low Air loss mattress is set to 4 (250 lbs.). V3 stated the Low Air loss mattress has a sticker on it to let V3 know which number setting the resident needs. V3 stated that the supervisor is the one that updates the sticker. The mattress setting should be within the resident weights. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow MD order for daily weights for a dialysis resident. This failure has the capacity to affect 1 of 1 resident (R111) reviewed for dialysis in a total sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Hand Hygiene Policy. The facility failed to perform hand hygiene after direct resident contact. This deficient practice affects one resident (R 127) of three residents reviewed for hand hygiene in a total sample of 29 residents. On 12/09/2025 at 7:23am observed V12 (housekeeper) walking in the hall, second floor towards unit B wearing gloves pushing the janitor cart. V12 proceeded to open the door to unit Bs shower room, with gloves on, change out the garbage and place a new garbage bag, adjust the shower curtain, leave the shower room wearing the same gloves and proceed to walk pushing the janitor cart walking to wing A. On 12/09/2025 at 8:55AM observed V21 (Activity Aide) not wearing gloves to reposition R127 and not performing hand hygiene afterwards when walking out of R127s room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its abuse prevention policy by failure to report injury of unknown origin. This deficiency affects one (R3) of three residents reviewed for abuse prevention policy.

Inspectors wroteBased on interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when transferring resident using a mechanical lift. This affected one resident (R1) of three residents reviewed for falls. This failure resulted in resident (R1) falling from mechanical lift and sustaining a left displaced femoral neck fracture.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision on a resident who has significant risk for falls for one of three residents (R3) reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from allegedly being roughly handled, threatened, punched, and intimidated by an agency staff person; failed to assess resident of any injuries; and failed to train staff on screening, abuse prevention and investigation. This failure affected 1 (R1) of 3 residents reviewed for abuse from the sample of 3 and resulted in R1 abruptly ending her rehabilitation to discharge home due to the resident feeling unsafe and distressed for fear of agency staff's return.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and interview staff; failed to interview potential residents that may have been affected by the alleged abuser in the investigation; and failed to assess resident for any obvious injuries after the alleged abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and interview staff; failed to interview potential residents that may have been affected by the alleged abuser in the investigation; and failed to assess resident for any obvious injuries after the alleged abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interviews, and a review of records, the facility failed to follow its weight monitoring policy to prevent or reduce the risk of residents experiencing unplanned significant weight loss. This failure affected three of ten residents (R17, R28, and R61) who were reviewed for weight monitoring and weight loss as part of a sample of 40 residents. As a result, R17 experienced an unplanned weight loss of 6.15% over a 30-day period, R28 experienced a 15.3% weight loss over six months, and R61 experienced an 11.2% weight loss during a six-month period.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Oxygen Administration and CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure) support policy. The facility failed to ensure that humidifier bottle is with label and dated, failed to follow physician's order for oxygen administration and failed to obtain physician orders for the CPAP. This deficient practice affects four residents (R39, R66, R108 and R111) of four residents reviewed for respiratory care in a total sample of 40. Findings Include: On 3/11/25 at 10:00 AM, R39 was observed to have oxygen 2 liters via nasal cannula. There was no signage on R39's door noting oxygen in use. On 3/11/25 at 10:55 AM, oxygen in use signage was placed on R39's door. R39's physician order sheet reviewed and noted oxygen order at 2L/min via nasal cannula dated 2/13/25. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were able to communicate with staff with their preferred language and failed to maintain privacy and dignity for residents with a gastrostomy tube and indwelling catheter. This affected three residents (R5, R33, and R55) reviewed for residents rights, privacy and dignity in the sample of 40 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Investigation and Reporting policy. Facility failed to submit initial report timely to IDPH (Illinois Department of Public Health) of an allegation of abuse. This deficient practice affects two residents (R51 and R327) of three residents reviewed for Abuse investigation and reporting in a total sample of 40 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accurately assess one resident's (R55) pain, implement interventions, and monitor for the effectiveness of the interventions out of 3 residents reviewed for pain management in a sample of 29.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its infection control policy for enhanced barrier precautions and don the appropriate PPE (personal protective equipment) prior to providing direct resident care. This failure affected two residents (R33 and R39) out of three residents reviewed for infection control in a sample of 40.

Inspectors wroteBased on interview and record review, facility staff V3 (Certified nursing assistant, CNA) failed to report a fall to the nurse for one resident (R2). This failure resulted in R2 being transferred back into bed with no nurse assessment for over 10 hours. R2 was transferred to the hospital for a left ear laceration requiring eleven sutures and broken ribs for one of three residents reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough investigation of a resident's bruise of unknown origin and failed to notify the family member of the investigation outcome. These failures apply to one resident (R1) reviewed for injury of unknown origin in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its fall prevention program policy by failure to implement fall prevention interventions, failure to complete fall investigation after each fall incident and failure to update care plan consistent with developed intervention based on fall investigation to prevent future falls. This deficiency affects all three residents (R1, R2 and R3) reviewed for resident safety and fall prevention program.

Inspectors wroteBased on interview and record review, the facility failed to adequately supervise one (R2) resident at risk for falls, a total assist resident and dependent on staff supervision/assistance with all ADL's (Activities of Daily Living); failed to provide assistive device of foot rests on a geriatric wheelchair to prevent sliding/falling; and failed to maintain functionality of bed in order to lower close to the ground. This failure affected one resident (R2) of 9 residents reviewed for accidents/hazards/supervision and resulted in R2 being transferred to the emergency department after a fall from a geriatric wheelchair and diagnosed with a right tibial fracture; and transferred again 11 days later to the emergency department after another fall from a malfunctioning bed.

Inspectors wroteBased on interview and record review, the facility failed to adequately supervise one (R73) resident who has a history of falls and required staff supervision/assistance with all Activities of Daily Living (ADLs). This failure affected one resident (R73) of seven residents reviewed for accidents and resulted in R73 being diagnosed with a displaced nasal bone fracture.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for food service and sanitation by not ensuring dishes were cleaned and sanitized at the appropriate temperatures, not ensuring kitchen staff performed hand hygiene when required, and not ensuring kitchen staff wore hair coverings appropriately. This failure applies to all 98 residents in the facility receiving meals from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have a policy for pest control and failed to implement effective pest control treatments and interventions. This failure applies to all 98 residents in the facility receiving meals from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its enhanced barrier precaution policy by failing to place any signage with informational material on resident's doors or making personal protective equipment (PPE) available inside or outside resident's room. This failure affected 9 residents on the first floor and 17 residents on the second floor who are currently receiving wound care, have an indwelling urinary catheter/ IV line/ G-tube at the facility, and have the potential to affect all 104 residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse in accordance with facility policy and procedure. The facility staff failed to report an allegation of abuse made by one resident (R52) to the abuse coordinator. Findings Include: R52 is a [AGE] year old female who resides in the facility with multiple diagnoses including but not limited to the following: disorder with mixed anxiety and depressed mood and dementia. Progress note dated 3/2/24 written by V17 (Registered Nurse) states in part but not limited to the following: R52 is alert and verbally responsive. R52 is complaining of the evening certified nursing assistant (CNA) removing her clothes, grabbing her, and walking with her. Informed to V1 (Administrator). Total body assessment done. No injuries noted. New order for urinalysis with culture sensitivity. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by failing to immediately suspend a staff accused of physical abuse to a resident pending investigation. This failure affected one (R85) of two residents, who were reviewed for staff to resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two residents (R22, R77) who were assessed with limited range of motion with restorative nursing services. This failure has the potential to affect all residents within the facility who are not receiving skilled therapy services. Findings Include: 1. R22 is a [AGE] year old male who resides in the facility with multiple diagnoses including but not limited to the following: anxiety depression, HTN, seizure disorder. On 4/29/24 at 11:15AM, R22 was interviewed regarding restorative therapy. R22 said, I barely ever get out of bed anymore and never receive any restorative therapy. My left leg is contracted and I never get any range of motion to this leg. I have never received any restorative therapy at all much less regarding my contractures. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for feeding assistance by not ensuring feeding assistance was provided for a resident at risk for weight loss who required extensive feeding assistance. This failure applies to one of four residents (R104) reviewed for nutrition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse prevention by not ensuring an agency staff received a thorough criminal background check, not identifying a resident's behaviors that increase their risk for abuse, and not ensuring an abuse risk or behavior care plan was developed for a resident with a history of refusing care. This failure applied to one of one (R1) resident reviewed for abuse and resulted in R1 being physically and verbally abused and sustaining physical and psychosocial harm.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures to ensure a resident who was at risk for and exhibiting signs of malnutrition was receiving nutrition supplements and snacks as ordered. This failure applied to one of three residents (R1) reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to administer physician ordered pain medication consistent with professional standards of practice for a terminally ill resident (R1) of 3 residents reviewed for pain management. This failure resulted in R1 crying and yelling out in extreme pain. The facility also failed to administer pain medications after an unwitnessed fall after showing signs of pain (moaning) and led to adverse consequence of transfer to an acute hospice facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment free from accidental hazards to prevent falls and injuries for 3 (R1, R2, R3) of 3 residents reviewed for accident/hazards; failed to assess fall risk and provide fall interventions; failed to monitor R1 who was found face first in between a dresser drawer and bed for an undetermined amount of time.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide end of life hospice services in accordance with professional standards of practice and hospice agreement by failing to administer medications as ordered and failed to notify hospice of a significant fall. This failure affected 1 (R1) of 3 residents reviewed for hospice.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in a timely manner for residents with suspected injuries, who had orders for x-rays and resulted in delay of treatment for injuries. This failure applied to two (R2, R3) of three residents reviewed for resident injury and resulted in R2 and R3 waiting over 24 hours after injury to be transferred to hospital for further evaluation and treatment of fractures.

Inspectors wroteBased on interview and record review, the facility failed to follow residents' plan of care by not monitoring a resident (R1) at all times and keeping the resident free from injury; and failed to conduct a proper resident transfer by utilizing only one staff member for a resident (R3) assessed to require two staff members for transfers. These failures applied to two (R1, R3) of three residents reviewed for resident injury and resulted in R1 having an unwitnessed fall in room and obtaining a left wrist fracture and R3 obtaining a right ankle fracture during improper transfer.

Inspectors wroteBased on interview and record review, the facility failed to document administration of Parkinson's Medication as ordered for one (R2) of three residents reviewed for documentation of medication administration.