Below 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 Palos during CMS and state inspections, most recent first.
A resident with diabetes and other chronic conditions refused Jardiance because it made him sick, but an RN documented the medication as given on the MAR and did not notify the physician at the time. The resident said staff kept giving the medication despite his refusal, while later interviews showed an LPN had reported the refusal to the DON and the attending MD had heard about it and told staff to hold the medication. The facility’s medication pass policy required signing the MAR after administration, and staff acknowledged the refusal should have been documented as refused.
Failure to Protect Resident from Alleged Physical Abuse: A resident with metabolic encephalopathy and unspecified dementia alleged that a CNA kicked her in the leg and pulled her hair inside an elevator after flinging her wheelchair. The nurse noted a small red discoloration and slight swelling on the resident’s right shin, and the shower sheet documented a bruise/hematoma. Video showed the CNA enter after the resident and exit before the resident, but it did not capture what occurred inside the elevator; the CNA did not recall the interaction.
Failure to Implement Fall Care Plan Interventions: Two residents with documented fall risk had ordered fall interventions not in place or not functioning. One resident with cognitive impairment was observed without the floor mat specified in his care plan, and another resident with severe cognitive impairment was observed with a wheelchair chair alarm that was not working until the battery was replaced. Both residents had recent falls documented in their records.
Surveyors found that the facility did not consistently implement fall care plan interventions for three cognitively impaired, high fall-risk residents. One resident with a prior hip fracture and a care plan requiring a bed alarm had a nonfunctioning alarm on repeated observations, and the family reported the alarm was not always activated. Another resident at risk for falls was seen getting out of bed and ambulating unsteadily to the bathroom without the bed alarm sounding, despite a care plan requiring its use. A third high-risk resident with a history of falls was observed in an elevated bed with the bed remote out of reach and the call light stored in a drawer, contrary to care plan directives to keep the bed in the lowest position and needed items within reach.
A resident with Parkinson’s disease, mild cognitive impairment, and other conditions had a physician order for daily Nuplazid to treat hallucinations, but the medication was never obtained or administered. The MAR showed missed doses over several days, and a nurse’s documentation that the drug was given on one date was later identified as a clerical error. The DON stated the drug was thought to be a VA specialty medication that was never received, while the pharmacist reported that Nuplazid required high-cost approval and that requests for this approval to the DON went unanswered, preventing delivery. The resident’s family member reported that the resident needed the hallucination medication but did not receive it during the stay.
A resident with dementia, Alzheimer’s disease, and lung cancer developed a scattered rash on the arms, chest, and stomach that was later documented by a physician as possibly scabies, with a plan for treatment using permethrin cream and appropriate isolation. The MAR showed permethrin applications on two occasions, but there were no corresponding physician orders for contact isolation, no documentation of isolation on the infection control log, and no evidence the resident was ever placed on isolation or moved to a private room. Staff, including a CNA, former wound care coordinator, physician, and DON, all stated that residents treated for scabies should be placed on contact isolation with appropriate PPE, yet they either were unaware of this resident’s scabies treatment or did not recall any isolation being implemented, contrary to the facility’s infection prevention and control policy requiring transmission-based precautions when indicated.
A resident with multiple comorbidities and a documented high fall risk care plan fell from bed and sustained a displaced humerus fracture, head laceration, and facial contusions while receiving ADL care from an agency CNA. The CNA, caring for the resident for the first time, reported receiving no information about the resident’s history or fall risk and described providing in‑bed care with the resident on her side, without bed rails in place. The resident consistently stated that the CNA let go of her during changing, that the bed was high, and that there were no rails to prevent her from rolling out of bed, and denied reaching for any object or preferring to be at the bed’s edge. An LPN responding to the incident found the resident on the floor with active head bleeding, did not recall side rails being present, and stated she had not been told the resident was a fall risk. Another agency LPN also did not consider the resident a fall risk. When surveyors requested a fall prevention policy, the administrator produced only a fall occurrence policy, indicating the lack of a specific fall prevention policy and procedures for communicating fall risk and interventions to staff.
A resident with multiple comorbidities, a history of falls, and documented high fall risk required extensive assistance for bed mobility and incontinence care per the care plan and MDS/CAA. An agency CNA, who had not previously cared for the resident and reported receiving no report on the resident’s care needs or fall‑prevention training, provided ADL care with the resident in a side‑lying position and removed stabilizing support while cleaning after a large BM, during which the resident reached toward the bedside table and rolled out of bed. The resident sustained a right humerus fracture and a laceration above the eye. Interviews with an LPN and an agency LPN showed they did not recognize the resident as a fall risk, were unaware of the high fall‑risk status, and reported no in‑service training from the facility on fall prevention, demonstrating a failure to implement and communicate the comprehensive fall‑risk care plan.
A resident with multiple comorbidities and a history of falls was assigned to an agency CNA whose competency in fall prevention and facility safety protocols had not been verified. During ADL care, the CNA, who had not been oriented to the resident’s fall risk, language needs, or specific care requirements, positioned the resident on her side while cleaning a large BM; the resident reached toward the bedside table, rolled from the bed, and sustained a right humerus fracture and a facial laceration. Facility orientation records for the CNA showed only a mass strike‑through over numerous training topics, including fall prevention, with no documented instructor validation, and an agency LPN reported receiving no in‑service training from the facility. The administrator could provide only a fall occurrence policy, and staff education materials addressed post‑fall procedures rather than proactive fall prevention.
A resident with multiple chronic conditions and moderate cognitive impairment sustained a right femoral neck fracture during peri-care when a CNA inadvertently overturned her leg, causing her to partially roll out of bed. Although the x-ray confirmed the fracture the same day, the DON was not informed until several days later, resulting in the facility failing to report the major injury to IDPH within the required 24-hour period.
The facility failed to ensure a safe environment and adequate supervision for three residents at risk for falls. Staff did not consistently follow procedures for safe repositioning, reporting falls, or implementing individualized fall prevention interventions. One resident sustained a femoral neck fracture after falling from bed due to lack of proper assistance and equipment, while other residents experienced unsafe transfers and lacked access to functioning alarms or call lights.
The facility did not update care plans for three residents after falls, omitting new interventions such as assistive devices, increased monitoring, and floor mats, even though these were implemented following the incidents. These updates were required by facility policy and were not reflected in the residents' care plans.
A dependent resident with quadriplegia and multiple comorbidities, assessed as high risk for falls, was left unattended on his side in bed at a raised height while a CNA retrieved supplies. The resident fell from the bed, sustaining a laceration to the right eyebrow that required sutures and an ER visit. Facility staff and leadership confirmed that the resident was not positioned safely according to care plan and policy requirements, resulting in a failure to implement effective fall prevention interventions.
Two residents with a history of falls were admitted to a facility without adequate fall prevention measures, resulting in significant injuries. Despite known risks, necessary interventions such as bed alarms and caregiver supervision were delayed. The facility failed to incorporate family input and past medical history into care plans, leading to falls and injuries.
The facility failed to maintain sanitary conditions in food preparation, affecting all residents. Staff were observed changing gloves without hand hygiene, not sanitizing surfaces after cleaning, and using a wet food processor, violating facility policies. Hair was also improperly restrained, risking contamination.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. One resident's care plan lacked necessary fall prevention interventions, another experienced delays in being assisted out of bed, and a third did not receive timely therapy for a hand contracture. Additionally, a resident's mood disturbances were not addressed in their care plan.
The facility failed to label insulin pens with access and discard dates for two residents and improperly disposed of expired medications. Insulin pens were found without necessary labeling, and expired stock medications were discarded inappropriately, contrary to facility policy. The ADON and DON confirmed these oversights, highlighting a breach in medication management protocols.
The facility failed to implement proper infection control measures, including the use of PPE and catheter care. A CNA did not change soiled gloves during ADL care for a resident with hepatitis C. A resident's urinary catheter bag was improperly handled, dragging on the floor. Additionally, a podiatry assistant and podiatrist did not follow enhanced barrier and droplet precautions, failing to wear gowns or perform hand hygiene when moving between rooms of residents with gastrostomy tubes and COVID-19.
A resident with COPD and dementia was found self-administering a Combivent inhaler and eyedrops without a proper assessment or physician's order. The facility's policy requires evaluation and authorization for self-administration, which was not followed, as confirmed by the DON.
A resident with partial paralysis and dementia experienced a deficiency in care due to the facility's failure to provide timely restorative services for a contracted left hand. Despite the need for therapy being identified in the admission assessment, the resident did not receive necessary evaluations and treatment, leading to a deficiency in care.
A resident with a complex medical history sustained a clavicle fracture due to inadequate interventions for safe repositioning. Staff inconsistencies and lack of documentation regarding the resident's care needs contributed to the deficiency. The resident expressed fear of falling out of bed, and there was no documentation of a turning and repositioning program in the care plan.
A resident with a right clavicle fracture experienced untreated pain due to the facility's failure to conduct timely pain assessments and administer appropriate pain management. Despite the resident's complaints and a history of significant medical conditions, there were gaps in pain documentation and communication among staff, resulting in the resident's pain escalating to a constant severity of 10 out of 10.
A resident with multiple diagnoses, including a vertebra fracture and dementia, experienced an acute clavicle fracture, but the facility failed to document restorative assessments and interventions accurately. Despite being on a turning program, there was no record of it, and CNAs reported inconsistencies in assistance needed. The DON admitted the absence of an incident report, and pain assessments were not documented. The care plan was updated posthumously, and the facility's documentation policy was not provided.
Medication Refusal Incorrectly Documented as Given
Penalty
Summary
The facility failed to ensure staff followed professional standards of practice when administering medication to a cognitively intact resident with multiple diagnoses including type 2 diabetes, polyneuropathy, venous insufficiency, hypertensive heart disease, and major depressive disorder. The resident stated that he had been at the facility for about 3 weeks and had complained that he did not want to take Jardiance because it made him sick, but staff were still giving it to him. He reported that he removed the medication from the cup and refused to take it. The active physician order showed Empagliflozin 10 mg daily for diabetes, and the May MAR showed the medication signed as given at 9:00 AM. During interview, an RN stated she had given the resident all of his medications and that he took them, but then acknowledged that he refused Jardiance, said it caused upset stomach, and that she disposed of the medication. She also stated she had not marked it as refused or notified the physician and said she was going to go back and fix the MAR. An LPN later stated the resident refused Jardiance and that she informed the DON, while the attending physician said he heard about the medication refusal about a week earlier and told staff to hold the medication until he saw the resident again. The DON stated she was unaware of the refusal until it was brought to her attention during survey and confirmed the medication was discontinued. The facility policy stated MAR documentation should occur after medication is administered, and the administrator stated the facility did not have a policy on medication refusal.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA was alleged to have kicked the resident in the leg and pulled her hair inside an elevator. The resident was a female with diagnoses of metabolic encephalopathy and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident reported that she entered the elevator, the staff member flung her wheelchair, and then kicked her in the right leg. She stated she immediately reported the incident when she came out of the elevator. The assigned nurse stated the resident reported being physically assaulted inside the elevator by the CNA and that a complete body assessment found a small red discoloration and slightly swollen area on the resident’s right shin. The shower sheet documented a bruise/hematoma on the right leg shin. The police report also documented that the resident alleged she was pushed in her wheelchair, kicked in the leg, and punched in the face/head, and that the nurse told police the bruises and hematoma were fresh and not present before the incident. The CNA stated she did not recall whether the resident was in the elevator and said her mind was preoccupied, so she did not notice if there was any interaction with the resident. The administrator stated the facility reviewed video and saw the CNA enter the elevator after the resident and exit on the first floor before the resident, but the camera could not show what happened inside the elevator. The facility reported the allegation to the state agency and the abuse policy stated the facility is to provide care in an environment free from abuse, mistreatment, neglect, and corporal punishment.
Failure to Implement Fall Care Plan Interventions
Penalty
Summary
The facility failed to implement fall care plan interventions for two residents who were identified as fall-risk residents. One resident, a male with mild cognitive impairment and diagnoses including bipolar disorder and a neoplasm of the tongue, was observed in bed without the floor mat on the right side that was listed in his fall care plan. A folded floor mat was instead seen leaning against the bedside drawer on the left side. The CNA stated she was about to give him a shower and would put the floor padding back after the shower. The resident’s record also documented an unwitnessed fall with a right forehead bruise and another fall with no injury. A second resident, a female with severe cognitive impairment, was observed in her wheelchair with a nonfunctioning chair alarm. The CNA stated the alarm was not working and needed a new battery. The restorative director later replaced the battery and the alarm began working. The resident’s fall care plan included use of a chair alarm to alert staff when she attempted to get out of bed unassisted, and her record documented a fall with no injury. The DON stated it was everyone’s responsibility to test the chair alarm and that staff were supposed to implement fall interventions to avoid further falls and injuries.
Failure to Implement Fall Care Plan Interventions and Maintain Functional Bed Alarms
Penalty
Summary
The deficiency involves the facility’s failure to implement fall care plan interventions, specifically bed alarms and environmental safety measures, for residents identified as high risk for falls. One resident with moderate cognitive impairment and a care plan calling for a bed alarm to alert staff of unassisted bed exits was found with a nonfunctioning bed alarm on multiple observations. The resident’s daughter reported that the resident does not walk, had sustained a hip fracture of unknown origin, and that the bed alarm was not always activated. On subsequent observations, staff identified that the bed alarm was not working due to battery and/or equipment issues, and the alarm was not blinking or sounding until the entire alarm set was replaced. Another resident with severely impaired cognition and a documented fall risk due to impaired cognition and mobility was observed getting out of bed, walking unsteadily, and going to the bathroom without the bed alarm sounding, despite a care plan intervention requiring a bed alarm to alert staff of unassisted bed exits. A third resident with severely impaired cognition, high fall risk due to impaired mobility, history of falls, and impaired cognition was observed in an elevated bed with the bed remote hanging behind the footboard and the call light touch pad stored inside a bedside drawer, contrary to the care plan interventions requiring the bed to be in the lowest position and commonly used items, including the call light, to be within easy reach. Staff confirmed that this resident was on fall risk and that the bed should be low and the call light accessible. These observations occurred despite a facility policy stating that residents at high risk for falls will be provided with fall interventions.
Failure to Obtain and Administer Prescribed Hallucination Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer a prescribed hallucination medication, Nuplazid 34 mg daily, for a male resident with mild cognitive impairment, Parkinson’s disease, a left femur fracture, and a bone density disorder. The physician ordered Nuplazid to start on 3/2/26, but the Medication Administration Record shows the resident did not receive the medication on 3/2/26, 3/3/26, or 3/4/26. The Physician Order Sheet indicates the medication was discontinued on 3/4/26. A nurse initially documented that Nuplazid was administered on 3/4/26, but later provided a statement that this entry was a clerical error, clarifying that the medication was not available, was never administered, and was discontinued by the attending physician on that date. The DON confirmed that the resident never received Nuplazid during the stay, explaining that the resident was admitted with this order and that the medication was believed to be a specialty drug from the VA hospital, which the facility did not receive. The DON also stated that medications are normally obtained from the pharmacy within 8 hours. The pharmacist, however, stated that Nuplazid is not a specialty medication but requires high-cost approval, and reported sending an email and voice message to the DON requesting this approval, which was not received, resulting in the medication not being delivered. The resident’s concerned party reported being present most of the time and stated that the resident needed his hallucination medication but did not receive it during the stay.
Failure to Implement Contact Isolation for Resident Treated for Suspected Scabies
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of a resident being treated for suspected scabies. The resident, an older adult with dementia, Alzheimer’s disease, and lung cancer, had a scattered rash on both arms, chest, and stomach documented on 12/25/25, with some scabbing and no signs of itching. A physician note dated 1/13/26 documented that the rash was possibly scabies, with a plan to treat with permethrin cream and implement appropriate isolation. The Medication Administration Record for 01/2026 showed the resident received permethrin cream on 1/14/26 and 1/22/26 for a rash. However, review of the Physician Order Sheet from 12/21/25 to the present revealed no order for contact isolation related to rash or scabies, and the Infection Control Isolation Log for the last three months did not list the resident as having been on isolation. Staff interviews further demonstrated that isolation precautions were not implemented for this resident while being treated for suspected scabies. A CNA reported the resident had a rash on the arms, chest, and back a couple of months prior and stated that residents treated for scabies are supposed to be placed on isolation immediately, but the CNA was not aware this resident had been treated for scabies and denied ever seeing the resident on isolation, noting it was the nurse’s responsibility to enter isolation orders and inform staff. The former Wound Care Coordinator stated that when scabies is suspected, nurses contact the physician for orders and residents should be placed on contact isolation and moved to a private room because the condition is very contagious. The medical physician confirmed that residents treated with topical ointment for suspected scabies should have contact isolation ordered, and the DON stated that residents treated for scabies should be placed on isolation and moved to a room alone, but did not recall this resident being on isolation in the prior couple of months. The facility’s Infection Prevention and Control policy required provision of transmission-based precautions, including contact precautions with gown and glove use, when indicated, but these measures were not documented or implemented for this resident.
Failure to Communicate High Fall Risk and Implement Fall Prevention During ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at high risk for falls was free from accident hazards and received adequate supervision and assistive devices during care. The resident is an alert and oriented, predominantly Polish‑speaking older adult with multiple comorbidities including type II diabetes, COPD, atrial fibrillation, hypertension, anxiety disorder, history of falls, and prior humeral fracture. The resident’s care plan, dated 5/12/25, identified her as at high risk for falls due to history of falls, impaired mobility, weakness, and multiple comorbidities, with interventions including keeping the bed in a low position, encouraging slow transfers and position changes, frequent toileting, having commonly used items within reach, and use of a low bed. Despite this, on observation on 1/2/26, the resident was seen in bed with the bed raised to waist height and no fall mats or other fall prevention measures in place. On the date of the fall, an agency CNA provided ADL care to the resident for the first time without being oriented to the resident’s high fall risk status or specific care needs. According to the facility’s incident report, the CNA had the resident lying on her left side, with one hand on the resident’s rib cage to stabilize her while washing with the other hand, when the resident began to roll out of bed; the CNA attempted but failed to stop the fall. The resident consistently reported in interviews, including through a Polish‑speaking surveyor and in a post‑fall statement interpreted by a staff member, that the CNA let go of her while changing her, that there were no side rails in place, and that she then rolled out of the bed and fell. The resident denied reaching for any object or preferring to be at the edge of the bed or using the nightstand for support, and the care plan contained no documentation of such preferences, contradicting the facility’s later assertion that the resident’s own positioning preferences contributed to the fall. Staff interviews further demonstrated a lack of communication and understanding of the resident’s fall risk status and fall prevention measures. The agency CNA stated that no one told her anything about the resident’s history or that she was a high fall risk, that it was her first time caring for the resident, and that she did not recall receiving fall prevention training at the facility. She also confirmed there were no bed rails in place and that she did not understand the resident because the resident did not speak English. The LPN on duty at the time of the incident reported finding the resident on the floor with active head bleeding and stated that the CNA told her the resident fell when she was turned too far during cleaning; the LPN did not recall any side rails being present and stated that if there had been side rails, the resident might not have rolled out of bed. This LPN also stated she did not consider the resident a fall risk and had never been told the resident was high risk for falls. An agency LPN caring for the resident later also stated she did not consider the resident a fall risk and could not describe facility fall prevention measures, indicating she relied on agency training. When surveyors requested a fall prevention policy, the administrator provided only a Fall Occurrence policy focused on assessment and care planning after falls, and confirmed that was the only policy, indicating the absence of a documented fall prevention policy and procedure for communicating fall risk and interventions to staff. The fall resulted in the resident sustaining a displaced fracture of the right humerus, a head laceration above the right eye with active bleeding requiring Steri‑Strips, facial contusions, and a hematoma and bruising of the right eye and right side of the face, as confirmed by hospital records and NP documentation. The resident reported ongoing pain in both shoulders and difficulty holding objects after the fall. The facility’s investigation notes and staff statements attempted to attribute the fall to the resident’s actions or preferences, but these claims were not supported by the care plan, resident interviews, or contemporaneous staff accounts. Overall, the deficiency centers on the facility’s failure to orient agency staff to the resident’s high fall risk, failure to implement and communicate care‑planned fall prevention interventions (including bed position and assistive devices such as side rails), and failure to maintain an environment free from accident hazards, which directly preceded the resident’s fall and injuries.
Failure to Implement and Communicate High Fall-Risk Care Plan During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to implement an established comprehensive care plan for a resident identified as high risk for falls and dependent for toileting hygiene and bed mobility. The resident, an alert and oriented, predominantly Polish‑speaking older adult with multiple comorbidities including a history of falls and fractures, had a care plan and MDS/CAA documentation indicating high fall risk and a need for extensive assistance of at least one staff member for bed mobility and incontinence care. Care plan interventions included maintaining the bed in a low position, encouraging slow transfers and position changes, frequent toileting, and keeping commonly used items within reach. Despite this, on the date of the incident, an agency CNA provided incontinence/ADL care with the resident in a side‑lying position, using one hand to stabilize the resident and the other to clean her after a large bowel movement. The CNA reported that the resident reached toward the bedside table and then rolled out of the bed, and the CNA was unable to prevent the fall. Following the fall, the nurse assessed the resident, who complained of right shoulder pain and had a laceration above the right eye; the resident was sent to the ED and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Interviews revealed that the agency CNA had not previously cared for the resident, did not receive any report or endorsement about the resident’s care needs, did not know the resident was a fall risk, and reported not receiving fall‑prevention training from the facility. Additional interviews with an LPN and an agency LPN showed they did not consider the resident to be a fall risk, were unaware of the resident’s high fall‑risk status, and one LPN stated the resident had never fallen out of bed and that she was never told the resident was high risk for falls. Staff also reported there were no side rails on the bed and no communication board in use, and the agency LPN stated she did not receive in‑service training from the facility and could not describe fall‑prevention measures for this resident. These findings demonstrate that the facility failed to implement and communicate the resident’s comprehensive fall‑risk care plan and required level of assistance during bed mobility and ADL care, resulting in a fall with significant injury.
Failure to Verify Agency Staff Competency and Provide Fall Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received care from staff with documented competency and training, particularly in fall prevention and resident-specific safety needs. An agency CNA was assigned to provide ADL care to an alert and oriented, predominantly Polish‑speaking resident with multiple diagnoses including type II diabetes, right humerus fracture history, COPD, atrial fibrillation, hypertension, anxiety disorder, and a history of falls. During incontinence care, the CNA positioned the resident on her side with one hand on the resident’s rib/shoulder area and the other hand cleaning a large bowel movement. The resident then reached toward the bedside table or an item on it, rolled out of the bed, and fell to the floor. The CNA reported there were no bed rails, that she did not understand the resident due to the language barrier, that it was her first time caring for the resident, and that no one had given her any information about the resident’s care needs or fall risk status. Following the fall, the resident complained of right shoulder pain and had a laceration above the right eye, was sent to the ED, and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Record review showed that the facility’s orientation documentation for the agency CNA consisted of a form listing over two dozen training topics, including fall prevention and safety protocols, all marked only with a single continuous vertical strike‑through line and the CNA’s signature, without instructor initials, dates of completion, or evidence of observed competency by facility leadership. The CNA stated she did not recall receiving fall prevention training. An agency LPN caring for the same resident reported receiving no in‑service training from the facility, only from the agency, and incorrectly stated that the resident was not a fall risk despite being aware of a prior fall. When the surveyor requested a fall prevention policy, the administrator provided only a Fall Occurrence policy that addressed assessment and interventions after falls and confirmed there was no separate fall prevention policy. Review of the facility’s education modules showed staff were trained only on the fall occurrence policy, not on a proactive fall prevention framework. As a result, the agency CNA was assigned to a high‑risk resident without verified competency in the facility’s safety standards or resident‑specific fall prevention needs.
Failure to Timely Report Major Injury to State Agency
Penalty
Summary
The facility failed to follow its Incident Reporting Policy by not reporting a major injury to the Illinois Department of Public Health (IDPH) within the required 24-hour timeframe. A female resident with multiple diagnoses, including congestive heart failure, stage 3 sacral pressure ulcer, chronic kidney disease, seizures, lymphedema, and pulmonary hypertension, and a BIMS score indicating moderate cognitive impairment, sustained an acute right intertrochanteric femoral neck fracture. The injury occurred when a CNA, while providing peri-care in bed, inadvertently overturned the resident's right leg, resulting in the resident partially rolling out of bed. The resident complained of right hip pain following the incident, and an x-ray ordered by the attending physician confirmed the fracture. Despite the x-ray result being available on the evening of 5/9/25, the Director of Nursing (DON) was not made aware of the fracture until 5/13/25. The facility reported the incident to IDPH only after the DON became aware of the injury, exceeding the 24-hour reporting requirement. The facility's policy mandates that any serious injury, such as a fracture, must be reported to the state agency within 24 hours of discovery, but this protocol was not followed in this case.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement fall prevention interventions for three residents reviewed for falls. Staff did not consistently follow policy and procedures for turning and repositioning dependent residents, reporting falls, or ensuring that staff were aware of and implemented individualized fall prevention interventions. Equipment intended to prevent falls, such as alarms and assistive devices, was not always in place or functioning properly. One resident with significant medical conditions, including congestive heart failure and chronic kidney disease, was assessed as high risk for falls and dependent on staff for repositioning. During care, staff failed to use an assistive device or a two-person assist as required, resulting in the resident falling from bed and sustaining an acute femoral neck fracture with significant pain. Documentation and staff accounts of the incident were inconsistent, and the care plan was not updated to reflect necessary interventions. Staff were also unclear about the resident's fall prevention measures, and required equipment was not observed in use during the survey. Other residents with histories of falls and impaired mobility were also not provided with appropriate interventions. One resident, dependent on staff for transfers, experienced multiple falls and was observed being transferred unsafely by a single staff member without proper equipment, despite care plan requirements. Another resident, also at high risk for falls and with severe cognitive impairment, was left without accessible call light assistance and was not provided with required transfer devices or functioning alarms. Staff were observed not responding promptly to requests for assistance, and fall prevention interventions outlined in care plans and facility policy were not consistently implemented.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update comprehensive care plans for three residents following fall incidents, as required by policy and regulation. For one resident, after a fall occurred during peri-care when a CNA inadvertently overturned the resident's leg, the care plan was not updated to include the use of an assistive device in bed, despite this intervention being noted in the incident report. The resident's risk for falls care plan did not reflect the most recent fall or the new intervention. Another resident experienced a fall when attempting to get into bed independently after a CNA left to retrieve supplies. The care plan was not updated to include the fall or the preventive interventions implemented after the incident until the survey entrance date. A third resident, who had a pressure ulcer and was visually impaired, rolled off the bed, prompting the addition of bed rails, a bed alarm, and floor mats as immediate interventions. However, the care plan did not reflect the most recent fall or the addition of floor mats. These omissions occurred despite facility policy requiring that fall interventions be added to the care plan and revised as necessary.
Failure to Implement Effective Fall Interventions for High-Risk Dependent Resident
Penalty
Summary
A dependent resident with functional quadriplegia, atrial fibrillation, bradycardia, and hypertensive heart disease was assessed as high risk for falls and required staff assistance for all activities of daily living. The resident's care plan included interventions such as keeping needed items within reach, maintaining the bed in a low position, ensuring furniture was locked during care, and keeping the call light accessible. Despite these interventions, the resident experienced a fall resulting in a laceration to the right eyebrow that required sutures and an emergency room visit. On the night of the incident, a CNA was providing incontinence care to the resident, who was positioned on his side in bed. The CNA left the resident briefly to retrieve additional linen from a cart located by the door, leaving the resident unattended. During this time, the resident fell from the bed. The CNA reported that the bed was not in the lowest position but at about hip level, and no bed rails were in use. The resident was found on the floor, alert and oriented, with a wound on the right eyebrow and complaints of pain in both arms. The nurse on duty confirmed that the bed was waist high and that the resident had no bed rails. The nurse also stated that, for safety, the resident should have been placed on his back and the bed lowered before leaving the room, especially given the resident's quadriplegia. Interviews with facility leadership, including the DON and Administrator, revealed that staff are expected to ensure residents are left in a safe position before stepping away, which includes centering the resident in bed and lowering the bed. Both leaders agreed that, for a resident with quadriplegia, the safest position when left briefly would be on the back. Facility policies require individualized fall prevention interventions and safe positioning during care, but these were not consistently implemented in this case, leading to the resident's fall and injury.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement established fall prevention interventions for two residents, leading to significant injuries. One resident, a male with a history of frequent falls and multiple medical conditions, was readmitted to the facility without the necessary fall interventions in place. Despite recommendations for bed and chair alarms, caregiver supervision, and a toileting schedule, these measures were not implemented until after the resident experienced falls. The resident's care plan did not initially include these interventions, which were only added after subsequent falls occurred. Another resident, also a male with a complex medical history including cirrhosis, emphysema, and a history of falls, was admitted to the facility without adequate fall prevention measures. Upon admission, the resident was placed in a room far from the nurses' station and without bed sensors or railings. The resident experienced a fall resulting in a femur fracture shortly after admission. The facility did not incorporate information from the resident's family regarding his fall risk into his care plan, and necessary interventions such as bed alarms and side rails were not implemented until after the fall. Interviews with facility staff revealed that initial fall assessments were not adequately conducted, and personalized fall interventions were not tailored to the residents' needs. The Director of Nursing acknowledged that past medical history and family input should have been considered in the care plans. The facility's policies on fall risk assessment and care planning were not followed, resulting in a lack of timely and appropriate interventions for residents at high risk of falls.
Sanitation Deficiencies in Food Preparation
Penalty
Summary
The facility failed to adhere to its policies and procedures for maintaining sanitary conditions in food preparation, affecting all 96 residents. During an observation in the kitchen, several staff members, including the cook and the food service director, were seen changing gloves without performing necessary hand hygiene. This was a direct violation of the facility's hand hygiene policy, which mandates hand washing or the use of alcohol gel after removing gloves. Additionally, the cook was observed with hair exposed from the back of her hairnet, and a dietary aide had hair exposed from the sides of her hairnet, contrary to the facility's kitchen policy requiring full hair coverage to prevent contamination. Further observations revealed that surfaces were not sanitized after being cleaned with soapy water, and the food processor was not adequately dried before use. The food service director acknowledged that surfaces should be sanitized immediately after cleaning and that the food processor should be allowed to drain to prevent contamination. However, the food processor was used with noticeable water remaining, which could alter the consistency of pureed food and introduce contamination. These lapses in following established procedures highlight significant deficiencies in maintaining sanitary conditions in the facility's kitchen.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in care. For one resident, R7, the facility did not include necessary interventions in the care plan despite a history of frequent falls and recommendations from the interdisciplinary team. The care plan lacked interventions such as bed/chair alarms and a toileting schedule, which were only implemented after the resident experienced falls at the facility. Another resident, R16, experienced delays in being assisted out of bed, which was not addressed in her care plan. Despite grievances and family reports about the need for a get-up schedule, the care plan did not include this intervention. The resident was often left in bed for extended periods, and staff cited her weight as a reason for the delay in using the mechanical lift. For resident R45, the care plan did not address the need for therapy services for a hand contracture, despite a physician's note and family concerns. The resident's care plan lacked timely evaluation for a hand splint, which was only ordered months after admission. Additionally, resident R56's care plan did not include interventions for mood disturbances, despite documented symptoms of depression and family concerns about the lack of social services support.
Medication Labeling and Disposal Deficiency
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and disposal of medications, specifically insulin pens and expired stock medications. During an inspection, a surveyor observed that insulin pens for two residents, R14 and R5, were not dated when first accessed, nor were they labeled with a discard date. The insulin pens, which had been previously accessed, were found in the medication carts without the necessary labeling, contrary to the facility's policy that requires insulin pens to be dated upon opening and discarded within a specified period. Additionally, the surveyor found seven expired bottles of house stock medications in the medication carts, which were not disposed of according to the facility's procedures. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the oversight regarding the insulin pens and the improper disposal of expired medications. The ADON was initially unsure of the duration insulin pens remain viable after opening but later confirmed they should be discarded after 28 days. The DON reiterated that insulin pens should be dated upon first use and that expired medications should not be discarded in trash bins on medication carts, as this poses a risk of contamination and potential harm. The facility's policy mandates that expired medications be removed from circulation and disposed of using a drug buster or returned to the pharmacy, which was not followed in this instance.
Infection Control Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several observed deficiencies. A Certified Nurse Assistant (CNA) was seen providing activities of daily living (ADL) care to a resident with chronic viral hepatitis C without changing soiled gloves between tasks, such as wiping the resident's face and cleaning the genital area. This practice risks cross-contamination and violates standard infection control protocols. Another deficiency was observed with a resident who had an indwelling urinary catheter. The resident's urine bag was not kept in a privacy bag and was seen dragging on the floor as the resident moved in a wheelchair. This improper handling of the catheter and urine bag increases the risk of contamination and infection, as confirmed by a Registered Nurse (RN) who acknowledged the need for the catheter and tubing to be kept off the floor. Additionally, a podiatry assistant and podiatrist failed to adhere to enhanced barrier precautions and droplet precautions while providing care to residents. They did not wear gowns or perform hand hygiene when moving between rooms of residents with gastrostomy tubes and active COVID-19 infection. This lack of adherence to infection control measures, such as wearing appropriate personal protective equipment (PPE) and performing hand hygiene, further highlights the facility's failure to prevent the transmission of infectious agents.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess and evaluate a resident for self-administration of medications, specifically inhalers and eyedrops, and did not obtain a physician's order for the eyedrops. The resident, a male with a history of pulmonary embolism, COPD, chronic respiratory failure with hypoxia, and unspecified dementia, was observed with a Combivent inhaler and two bottles of eyedrops at his bedside. The resident reported using the inhaler and eyedrops independently, despite the absence of a formal assessment or physician's order for self-administration. The facility's policy requires an interdisciplinary team to evaluate a resident's ability to self-administer medications safely and to obtain a physician's order for medications to be kept at the bedside. However, the Director of Nursing confirmed that the resident was not supposed to self-administer medications and that no assessment or physician's order was in place. This oversight indicates a failure to adhere to the facility's policies regarding medication administration and physician orders.
Failure to Provide Timely Restorative Services for Contracture
Penalty
Summary
The facility failed to provide necessary restorative nursing program services to a resident, leading to a deficiency in care. The resident, a male with a history of partial paralysis following a stroke, dementia, and a history of falling, was observed with a contracted left hand. Despite the resident's admission restorative assessment indicating a need for referral to physical and occupational therapy, the facility did not ensure timely evaluation and treatment for the contracture. The resident's care plan, initiated upon admission, required assistance with activities of daily living and included interventions for skilled rehabilitation therapy evaluation and treatment. However, it did not address the treatment for the left-hand contracture. The resident's family member reported being informed that therapy services were not provided due to insurance coverage issues, despite the resident having multiple medical insurances. The facility's Director of Nursing acknowledged that the resident should have been evaluated for a hand splint much sooner, as delays could lead to further deterioration and worsening of the contracture. The facility's policy mandates comprehensive nursing and restorative needs assessments upon admission, with appropriate services provided based on the resident's functional needs. However, the resident's contracture management, specifically the need for a splint, was not timely addressed, resulting in a deficiency.
Failure to Ensure Safe Repositioning Leads to Resident Injury
Penalty
Summary
The facility failed to develop appropriate interventions to safely turn and reposition a resident who expressed fear of rolling out of bed during repositioning. This deficiency resulted in the resident sustaining an acute clavicle shaft fracture. The resident had a complex medical history, including vertebra fracture, cognitive communication deficit, history of falling, dementia, depression, anxiety, and osteoarthritis. On a specific date, the resident complained of shoulder pain, and an X-ray revealed an acute clavicle fracture. Interviews with staff revealed inconsistencies in the care provided to the resident. A Licensed Practical Nurse (LPN) was notified by a hospice nurse about the resident's shoulder appearing swollen and reddened, prompting an X-ray. The resident reported pain during repositioning, and staff members had varying accounts of the assistance required for turning the resident. Some staff mentioned the resident's fear of falling out of bed and the lack of grab bars or rails, while others noted the resident's need for assistance from one or two persons during repositioning. However, there was no documentation of a turning and repositioning program in the resident's care plan. The facility's documentation and communication regarding the resident's care needs were inadequate. The Director of Nursing (DON) and other staff members were unsure of the level of assistance required for the resident's bed mobility. The resident's care plan lacked follow-up interventions to prevent reoccurrence of injury during repositioning. Additionally, the Medication Administration Record and hospice records indicated discrepancies in pain management and documentation, further highlighting the facility's failure to ensure adequate supervision and safety measures for the resident.
Failure to Conduct Timely Pain Assessment and Management
Penalty
Summary
The facility failed to conduct a comprehensive pain assessment for a resident after the new onset of pain persisted for more than 12 hours. This oversight affected a resident who had a right clavicle fracture, resulting in their pain escalating from intermittent to constant, with a severity rating of 10 out of 10. The resident's medical history includes vertebra fracture, cognitive communication deficit, symptoms involving the nervous system, history of falling, dementia, depression, anxiety, and osteoarthritis. Despite the resident's complaints of shoulder pain and the presence of a sling, the facility did not perform timely pain assessments or administer appropriate pain management. Interviews with staff revealed that the resident experienced significant discomfort when repositioned, yet there was a lack of communication and documentation regarding the resident's pain levels. The Director of Nursing acknowledged that pain should be assessed every shift and that a new onset of pain should prompt a call to the physician and a pain assessment. However, records show gaps in pain assessments and medication administration, with no pain scale ratings documented for several days. The hospice nurse had instructed the facility nurse to assess and administer medication as needed, but this was not consistently followed, leading to the resident enduring untreated pain for nearly 24 hours.
Incomplete Documentation and Lack of Incident Reporting for Resident Injury
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and accurately documented, particularly concerning restorative assessments and interventions to address care plan needs. The resident, who had multiple diagnoses including vertebra fracture, dementia, and osteoarthritis, complained of shoulder pain, which was later identified as an acute clavicle fracture. Despite being on a turning and repositioning program, there was no documentation of this program in the resident's records. Interviews with CNAs revealed inconsistencies in the assistance required for turning the resident, and there was no documentation of these observations in the resident's chart. The Director of Nursing acknowledged the absence of an incident report for the resident's injury and stated that the IDPH reportable served as documentation, which was not part of the resident's chart. A pain assessment was not documented, and there were no additional interventions recorded to prevent similar injuries. The restorative assessments were incomplete and were only filled out after the surveyor's inquiry. The care plan was updated to include the clavicle fracture after the resident's death, and the facility's policy for documentation was not provided upon request. The facility's policy required an incident report for all incidents, including injuries of unknown source, which was not adhered to in this case.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palos Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Palos Heights | 0.1 mi | ★★★★★ | 29 | 0 |
| Nexus At Palos | 1.8 mi | ★★★★★ | 23 | 2 |
| Chicago Ridge Snf | 2 mi | ★★★★★ | 8 | 1 |
| Elevate Care Palos Heights | 2.1 mi | ★★★★★ | 3 | 0 |
| Avantara Chicago Ridge | 2.5 mi | ★★★★★ | 5 | 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.