Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmony Healthcare & Rehab Ctr during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, prior stroke, orthostatic hypotension, repeated falls, unsteadiness, and severe cognitive impairment was care planned as high risk for falls, with interventions including keeping the bed in the lowest position and use of floor mats if appropriate. The resident was taken to the dining room in a wheelchair, where video later showed the resident becoming dizzy and falling from a chair, striking the head and sustaining a laceration requiring sutures, while staff in the room were occupied with other tasks and did not prevent the fall. During the survey, the resident’s bed was observed in a high position without floor mats, and an agency CNA reported not being aware of the resident’s specific fall precautions and that no floor mats were in place at the start of her shift. The fall coordinator confirmed the resident was appropriate for floor mats and that the care plan required the bed to be in the lowest position, and facility policy required high-risk residents to receive fall interventions.
A resident with CHF, HTN, CKD stage 3, and Alzheimer’s experienced a 48% weight gain over six months, with progressive edema, functional decline from partial assistance to dependence for toileting, and visible whole‑body swelling. Despite multiple notes identifying more than 55 lbs of weight gain, bilateral lower extremity edema, and concern for fluid retention, the facility did not document daily weights or I/O monitoring, did not adjust diuretics, and did not obtain a nephrology consult. A cardiology consult was ordered only after a change in condition involving significant edema and a brief loss of consciousness, and the resulting appointment was scheduled months later. The resident’s care plan called for monitoring and reporting changes in lung sounds, edema, and weight related to CHF and renal insufficiency, but these interventions were not effectively implemented, and the resident was ultimately hospitalized with acute decompensated heart failure and fluid overload requiring diuresis.
A resident with multiple serious diagnoses experienced a significant change in condition, including a drop in blood pressure and oxygen saturation. Despite these symptoms, the nurse on duty called a private ambulance instead of 911, delaying the resident's transfer to the hospital where they were diagnosed with septic shock. Interviews revealed a lack of urgency in responding to the resident's condition.
The facility failed to conduct care plan conferences for several residents, as required by policy. Despite having various medical conditions, these residents reported not attending any care plan meetings since admission. The MDS Coordinator confirmed the lack of documentation for these conferences, indicating a systemic issue in scheduling and execution.
A facility failed to follow individualized diet orders and pureed food preparation, affecting a resident on a pureed diet and 22 others. The resident did not receive the prescribed triple portions or water, and was mistakenly given juice, risking aspiration. The kitchen staff did not adhere to the diet spreadsheet, serving instant mashed potatoes instead of pureed scalloped potatoes, as confirmed by observations and staff admissions.
A facility failed to adhere to infection control practices, including improper medication handling and lack of PPE use. Staff did not perform hand hygiene during medication administration and failed to post Enhanced Barrier Precautions signage for residents with indwelling medical devices. These actions were contrary to the facility's policies, as confirmed by the Director of Nursing and Infection Preventionist.
The facility failed to maintain dignity and proper feeding practices for residents. Staff stood while feeding two residents, contrary to the policy of sitting at eye level to prevent choking and ensure dignity. Additionally, a resident was left waiting for a meal while others at the same table were served and finished eating, highlighting a lack of respect and dignity in meal service.
A resident with medical conditions including Hemiplegia and finger pain was found with Lidocaine cream at their bedside without a physician's order for self-administration. Facility staff confirmed that no assessment or order was in place, contrary to policy requirements, posing potential safety risks.
A facility failed to obtain a physician order and update the record with the correct code status for a resident with severe cognitive impairment and multiple diagnoses. The resident's code status was not documented, and the error was attributed to a possible oversight during readmission. The facility's policy requires advance directive information to be added to the Physician Order Sheet and reviewed periodically, but this was not done.
A resident with a complex medical history experienced a deficiency in care when their Advance Directives care plan was not updated following three hospitalizations and readmissions. The facility failed to document the resident's 'Full Code' status, as confirmed by the Social Service Director and Registered Nurse, due to an oversight during the readmission process. The Director of Nursing noted that orders are discontinued upon hospital admission and must be renewed, but the care plan was not updated as required by facility policy.
The facility failed to provide proper respiratory care for two residents, resulting in incorrect oxygen flow rates. A resident with COPD had an oxygen concentrator set at 3.5 LPM instead of the ordered 3 LPM, and the tubing was not labeled as required. Another resident with asthma had their oxygen set at 3.5 LPM instead of the prescribed 2 LPM. Both discrepancies were identified by nursing staff, who confirmed the residents could not adjust the settings themselves.
Two residents with cognitive and physical impairments were not provided with necessary adaptive eating equipment during mealtime, leading to difficulty in self-feeding and food spillage. Despite recommendations from therapists and indications on meal tickets, the facility failed to supply the required utensils and plate guards.
Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement effective fall precaution interventions for a resident identified as high risk for falls. The resident had multiple diagnoses including unspecified dementia, Alzheimer’s disease with late onset, cerebral infarction, orthostatic hypotension, repeated falls, unsteadiness on feet, osteoporosis, and adult failure to thrive. The MDS documented severe cognitive impairment with memory problems, substantial/maximal assistance needs for ADLs, partial/moderate assistance with mobility, bowel and bladder incontinence, and wheelchair use. The resident’s fall care plan identified high fall risk related to impaired mobility, poor safety awareness due to confusion, history of falls, and a recent fall, and included preferences for the bed to be kept in the lowest position and for a safe environment, with floor mats/floor pads at bedside “if appropriate.” Fall risk assessments documented high fall risk scores. On the day of the fall, progress notes show the resident was wheeled by staff to the dining room to participate in activities with staff supervision and later required transfer to the hospital for a laceration to the left eyebrow that required five sutures. The facility-reported incident documented that the resident fell in the facility and sustained this laceration. A registered nurse later stated she reviewed video footage showing the resident eating in the dining room, appearing to become dizzy, and then falling out of the chair, hitting her head on the floor and bleeding. The RN stated staff were present in the dining room but were busy doing other tasks and were unable to prevent the fall. During the survey, the resident was observed in the dining room in a wheelchair and later in bed. The bed was observed in a high position, not in the lowest position as specified in the care plan, and there were no floor mats in place while the resident was in bed. An agency CNA assigned to the resident stated she was not aware of the resident’s specific fall precaution interventions, noted the bed was not in the lowest position, and reported that when she started her shift the resident did not have floor mats in place. The fall coordinator/restorative nurse confirmed responsibility for entering fall interventions into the care plan, stated that care plans are updated after falls, and that all fall interventions are expected to be followed once implemented. She acknowledged that the care plan language for floor mats said “if appropriate,” that she had determined the resident was appropriate for floor mats, and that the care plan required the bed to be in the lowest position while in bed. The facility’s fall policy stated that residents at high risk for falls will be provided fall interventions and that interventions are to be added to the care plan and implemented.
Failure to Monitor and Treat Fluid Overload in Resident With CHF and CKD
Penalty
Summary
The deficiency involves the facility’s failure to identify and treat symptoms of altered cardiovascular status and fluid overload for a resident with chronic diastolic heart failure, essential hypertension, and stage 3 chronic kidney disease, resulting in a 53.4‑pound (48%) weight gain over six months and subsequent hospitalization for acute decompensated heart failure. The resident also had diagnoses including Alzheimer’s disease, shortness of breath, and obstructive sleep apnea, with moderately impaired cognition per the MDS. Over time, the resident’s functional status declined, as reflected in MDS Section GG toileting hygiene coding changing from partial/moderate assistance to dependent, and staff observations that the resident went from being able to get out of bed and use the bathroom with assistance to becoming bedbound, dependent on diapers, and visibly swollen over the entire body. Weight trends documented in the record show a progressive increase from 144.4 lbs in early February to 203.8 lbs by early August, with a progress note on 08/09/25 explicitly stating that the resident was re‑admitted following a CHF hospitalization and had triggered for significant weight gain of 7.6% in one month and 48% in six months, likely fluid‑related given the history of CHF and CKD3B. A 07/29/25 internal medicine progress note identified weight gain of over 55 lbs in six months, noted that nutritional intake had been closely monitored and Med Pass BID supplementation was under review, and directed that cardiology be consulted for volume status and cardiac contribution, intake/output be monitored, diuretics adjusted if needed, daily weights be obtained, and nephrology referral considered. However, daily weights and intake/output records were not found, no nephrology consult was ever ordered, and there were no documented diuretic adjustments. The cardiology consult order was not placed until 08/06/25, after a change in condition and hospitalization, despite earlier documentation that cardiology consultation was needed. Interdisciplinary and nursing documentation repeatedly identified concerns about fluid retention and edema without corresponding timely medical follow‑through. On 06/30/25, a visit note cited weight gain, increased need for ADL assistance, wheelchair dependence, and the need to monitor for CHF/CKD signs. On 07/27/25, the nutrition note documented a total gain of 55.4 lbs over six months, bilateral lower extremity swelling, concern for fluid retention, and referrals to the NP for labs and to cardiology for fluid status and CHF management, with instructions to continue monitoring weight and edema. The registered dietician later stated that the resident’s appetite had not changed, that edema was driving the weight gain, that the 48% weight gain was extremely significant and concerning, and that she communicated concerns to the ADON but never spoke directly with a physician. A CNA reported that as the resident gained weight, she experienced a lot of pain, no longer wanted to get out of bed, and became dependent on diapers, with visible swelling of the whole body. Nursing and provider interviews and records further demonstrate delayed response to significant edema and weight gain. An RN stated that at the beginning of her shift she noticed the resident’s significant edema and called the doctor, and while on the phone was informed that the resident had lost consciousness, leading to a 911 transfer. A progress note on 08/05/25 documented peripheral edema and a temporary loss of consciousness while eating, with the resident sent out via 911 for further evaluation. Hospital records from 08/10/25 and 08/13/25 documented cardiomegaly, pulmonary vascular congestion, pulmonary edema, bilateral pleural effusions, bibasilar atelectasis, decreased breath sounds with rales, bilateral leg edema, and a 15‑pound weight loss with diuresis since admission. The NP stated that weight gain had been concerning since March, that she wanted cardiology involvement but appointments take time, and that she assumed the resident had functional decline due to the weight gain and pressure from the weight. The transportation coordinator reported that no appointments were scheduled for the resident in July, and that when informed on 08/07/25 to schedule a cardiology appointment “ASAP in 1 week,” the appointment was set for October. Despite care plan directives to monitor and report changes in lung sounds, edema, weight, and signs of fluid overload related to renal insufficiency and altered cardiovascular status, the facility did not implement timely monitoring and specialist follow‑up as ordered and care‑planned, contributing to the resident’s acute decompensated heart failure and hospitalization.
Failure to Access EMS for Resident in Distress
Penalty
Summary
The facility failed to access Emergency Medical Services (EMS) for a resident experiencing a significant change in condition, which led to a delay in acute care. The resident, who was moderately cognitively impaired and had multiple serious diagnoses including intrahepatic bile duct carcinoma and hypertension, showed signs of distress with a drop in blood pressure and oxygen saturation. Despite these symptoms, the nurse on duty opted to call a private ambulance instead of 911, resulting in a delay in the resident's transfer to the hospital. The resident was eventually diagnosed with septic shock upon arrival at the hospital. Interviews with the nursing staff and physician revealed that there was a lack of urgency in responding to the resident's deteriorating condition. The nurse on duty admitted to being concerned about the resident's blood pressure but did not call 911, which was acknowledged as a mistake. The physician stated that the resident should have been sent to the hospital via 911 when the blood pressure dropped below 90. The Assistant Director of Nursing believed that the resident was being closely monitored and was stable enough to wait for a private ambulance, despite the resident's critical condition.
Failure to Conduct Resident Care Plan Conferences
Penalty
Summary
The facility failed to ensure that residents participated in care planning conferences, as required, for five residents in a sample of 33. These residents, who had various medical conditions such as respiratory failure, depression, anxiety, and diabetes, reported not attending any care plan meetings since their admission. The electronic health records (EHR) for these residents lacked documentation of care plan conferences, indicating a failure to conduct these meetings as per the facility's policy. Interviews with the residents revealed that they had not been involved in any care plan meetings, despite being cognitively intact or having only moderately impaired cognition. The MDS Coordinator, responsible for scheduling these conferences, confirmed that there was no documentation of care plan conferences being held for these residents. The facility's policy mandates that care plan conferences should occur within 72 hours of admission and quarterly thereafter, but this was not adhered to. The facility's policy outlines that care plan conferences should involve the interdisciplinary team and provide a platform for residents and their representatives to discuss their care plans. However, the lack of documentation and resident participation suggests a systemic issue in the scheduling and execution of these conferences. The MDS Coordinator admitted uncertainty about the scheduling process for new admissions and confirmed that no documentation was available to prove that invitations were sent out or that conferences were held.
Failure to Follow Individualized Diet Orders and Pureed Food Preparation
Penalty
Summary
The facility failed to adhere to the individualized diet orders and food plans for residents, specifically affecting one resident who was on a pureed diet. This resident, identified as R159, expressed dissatisfaction with receiving mashed potatoes at nearly every meal and noted that they were not provided with the variety of pureed foods listed on their meal ticket. Observations confirmed that R159 was not receiving the triple portions of pureed food as ordered, nor were they consistently provided with water, which was the only liquid allowed per their dietary restrictions. Instead, juice was mistakenly included on their tray, posing a risk of aspiration due to their swallowing difficulties. Further investigation revealed that the facility's kitchen staff did not follow the diet spreadsheet and recipes for pureed food preparation, affecting all 22 residents on pureed diets. The assistant cook admitted to not preparing the pureed scalloped potatoes as listed on the menu, opting instead to serve instant mashed potatoes. This deviation from the planned menu was confirmed during lunch observations, where residents on pureed diets were served mashed potatoes instead of the scheduled pureed scalloped potatoes. The facility's dietary director and registered dietitian acknowledged the importance of following meal tickets and recipes to ensure residents receive the appropriate nutrition and variety. The failure to provide the correct portions and liquids as per the meal tickets, along with the lack of adherence to the pureed diet recipes, highlights significant lapses in the facility's dietary management, potentially impacting the nutritional intake and safety of the residents.
Infection Control Deficiencies in Medication Handling and PPE Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration and resident care. Observations revealed that staff did not handle medications in a sanitary manner and failed to perform hand hygiene for several residents. Specifically, a registered nurse was observed accessing an IV site without wearing a gown and without Enhanced Barrier Precautions (EBP) signage posted, which is required for residents with indwelling medical devices. Additionally, the nurse did not perform hand hygiene after handling a blood pressure monitor and before preparing medications, which is a breach of standard infection control practices. Further deficiencies were noted in the facility's failure to post EBP signage for residents with indwelling medical devices, such as a gastrostomy tube. One resident with a feeding tube did not have the required EBP signage outside their room, which is necessary to alert staff and visitors to the need for personal protective equipment (PPE) and hand hygiene. The absence of signage was acknowledged by the staff, who admitted it was an oversight, and the Infection Preventionist confirmed the requirement for such signage to prevent cross-contamination. The facility's policies on Enhanced Barrier Precautions and hand hygiene were not adhered to, as evidenced by staff not wearing appropriate PPE during high-contact care activities and failing to perform hand hygiene before and after resident contact. The Director of Nursing and Infection Preventionist both emphasized the importance of these practices in preventing infection transmission, yet the observed actions of the staff did not align with these policies, indicating a systemic issue in the implementation of infection control measures.
Failure to Maintain Dignity and Proper Feeding Practices
Penalty
Summary
The facility failed to ensure that staff maintained proper feeding practices, which compromised the dignity and safety of residents. Two residents, one with hemiplegia and dysphagia and another with multiple diagnoses including dementia and kyphosis, were fed by staff members who stood rather than sat at eye level. This practice was contrary to the facility's policy and the staff's understanding that sitting at eye level is necessary to prevent choking and maintain dignity. The Director of Nursing confirmed that staff should sit while feeding residents to ensure proper observation and interaction. Additionally, the facility did not treat a resident with respect and dignity during meal service. One resident was left waiting for a meal tray while others at the same table were served and finished eating. This delay in serving the meal tray was acknowledged by the Director of Nursing as a dignity issue, as it is expected that residents seated together should receive their meals simultaneously. The facility lacked a specific policy for meal tray distribution, although it was recognized as a best practice to serve all residents at a table at the same time.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to determine the appropriateness of self-administration of medication for a resident, identified as R70, who was observed with Lidocaine 4% External Analgesic Cream on their bedside table. R70, who has medical diagnoses including Hemiplegia, Hemiparesis following Cerebral Infarction, and pain in the left fingers, stated that a nurse had given them the cream months ago for pain relief and that they used it every other day. However, there was no physician's order for R70 to self-administer the medication or to keep it at the bedside, as confirmed by the review of R70's Physician Order Sheet and electronic health record. Interviews with facility staff, including a Registered Nurse (RN), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), revealed that the facility's policy requires a doctor's order for self-administration of medication and for medications to be kept at the bedside. The staff acknowledged that R70 did not have such an order, and the potential risks of this oversight were noted, including the possibility of medication errors and safety issues. The facility's policies on medication pass and self-administration were reviewed, indicating that an assessment should be conducted to determine a resident's ability to safely self-administer medications, which was not completed for R70.
Failure to Update Resident's Code Status and Physician Orders
Penalty
Summary
The facility failed to obtain a physician order and update the resident record with the correct code status for a resident reviewed for Advance Directives. The resident, who has a severely impaired cognitive function as indicated by a BIMS score of 04, has multiple diagnoses including Alzheimer's Disease, Type 2 Diabetes Mellitus, and Chronic Kidney Disease, among others. During the survey, a registered nurse was unable to find the resident's code status in the computer system and had to consult with admissions/social service to verify it. It was discovered that there was no code status order for the resident at that time, which was acknowledged as an error by the Social Service Director, possibly due to a readmission oversight. The Director of Nursing stated that advance directives are presumed to be full code unless a DNR order is present, and the care plan was not updated as there was no change in code status. The facility's policy requires that advance directive information be added to the Physician Order Sheet and reviewed periodically, but this was not done in this case. The resident's care plan indicated that the resident's Power of Attorney wished for the resident to remain a full code, but this was not reflected in the physician orders until after the surveyor's inquiry.
Failure to Update Advance Directives After Hospital Readmissions
Penalty
Summary
The facility failed to ensure that a resident's Advance Directives care plan was revised following three hospitalizations and subsequent readmissions. The resident, identified as R85, has a complex medical history including Alzheimer's Disease, Type 2 Diabetes Mellitus, and Chronic Kidney Disease, among other conditions. Despite these hospitalizations, the care plan was not updated to reflect the resident's code status, which was supposed to be 'Full Code' as per the resident's Power of Attorney's wishes. During the survey, it was discovered that there was no code status order documented for R85, which was acknowledged as an oversight by the facility staff. The deficiency was identified when a surveyor inquired about R85's code status, and the Registered Nurse (V14) was unable to find it in the system. The Social Service Director (V4) confirmed the absence of a code status order, attributing it to an error during the readmission process. The Director of Nursing (V2) explained that all orders are discontinued upon hospital admission and must be renewed upon readmission, but the care plan was not updated as there was no change in code status. The facility's policy requires that Advance Directives be reviewed during reassessment and care planning processes, which was not adhered to in this case.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen administration. One resident, identified as R136, was observed using oxygen via nasal cannula with the concentrator set at 3.5 liters per minute (LPM), despite the physician's order for 3 LPM continuously. Additionally, the oxygen tubing for R136 was not labeled with the date it was last changed, contrary to the facility's policy requiring weekly changes and labeling for infection control purposes. The resident, who has chronic obstructive pulmonary disease (COPD) and moderately impaired cognition, relies on nursing staff to set the oxygen flow rate. Another resident, R50, was found with an oxygen concentrator set at 3.5 LPM, although the physician's order specified 2 LPM as needed for asthma. The resident's oxygen saturation was at 99%, and the rate was adjusted back to 2 LPM by a registered nurse. R50's medical history includes cerebral infarction, type 2 diabetes mellitus, and asthma, among other conditions. The discrepancy in oxygen flow rate was noted by the nurse, who confirmed that the resident could not have changed the setting independently.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to two residents, R96 and R135, during mealtime, which was necessary to facilitate self-feeding. R135, who has Huntington's disease and experiences involuntary movements, was observed using regular silverware instead of the recommended adaptive utensils with rubber handles, resulting in food spillage. The meal ticket for R135 indicated the need for a divider plate and adaptive utensils, but these were not provided. Similarly, R96, who has severe cognitive impairment and requires partial assistance with eating, was not provided with a plate guard as indicated on the meal ticket, leading to difficulty in scooping food and spillage. The Director of Nursing confirmed that adaptive eating equipment is recommended by therapists and is the responsibility of the kitchen to provide and clean. The Director of Therapy explained that adaptive equipment, such as weighted utensils and plate guards, is recommended to promote independence and prevent food spillage. Despite these recommendations, the necessary equipment was not provided to R96 and R135, affecting their ability to eat independently and maintain their level of functioning during mealtime.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Rehab At Fairmont | 0.2 mi | ★★★★★ | 27 | 0 |
| Ambassador Nursing & Rehab Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Irving Park Living & Rehab Ctr | 1.1 mi | ★★★★★ | 0 | 0 |
| Peterson Park Health Care Ctr | 1.2 mi | ★★★★★ | 5 | 0 |
| Foster Health & Rehab Center | 1.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.