Harmony Palos

In the surveyor’s words

From the most serious findings on record at Harmony Palos, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (R1) reviewed for accidents was free from accident hazards and received adequate supervision and assistive devices to prevent an avoidable fall. Specifically, the facility failed to ensure an agency CNA (V3) was oriented to R1's high fall risk status. This failure resulted in R1 sustaining a displaced humerus fracture, head laceration with active bleeding requiring sterile-strips, and facial contusions. […]

• Actual harm, isolatedF689Jun 11, 2025

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

• Actual harm, isolatedF689Apr 24, 2025

  Based on interview and record review, the facility failed to implement effective fall interventions and supervision for a dependent resident assessed as a high risk for falls. This failure affected one resident (R2) of four residents reviewed for falls. This failure resulted in (R2) having a fall, being sent out to the emergency room , and sustaining a laceration to right eyebrow requiring 3 sutures. Findings include: R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to: Functional quadriplegia, atrial fibrillation, bradycardia, and hypertensive heart disease with heart failure. […]

• Actual harm, isolatedF689Nov 21, 2024

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

• Actual harm, isolatedF686Feb 15, 2023

  Based on interviews and record review, the facility failed to consistently monitor, assess, and implement pressure relieving interventions to prevent the development of facility acquired pressure ulcers. This affected one resident of three (R1) residents reviewed for pressure ulcer prevention. This failure resulted in R1 developing a stage 3 pressure sore to the coccyx area, and a stage 2 pressure sore to the left buttocks. Findings include: Review of R1's medical record notes R1 was admitted to this facility on 1/25/23 with diagnoses including: severe sepsis with shock related to UTI (urinary tract infection) and pneumonia, malaise, acute respiratory failure with low oxygen levels, chronic obstructive pulmonary disease, heart failure, dementia, and diabetes. […]