Sharon Health Care Elms

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and interview, the facility failed to maintain one resident's (Resident R23) room in good repair of 24 residents' rooms observed during the initial tour for maintenance in a sample of 28. Findings include:Resident R23 was admitted on [DATE REDACTED] with a diagnosis of Malignant Neoplasm of the Right Lung.Resident R23's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R23 has a Brief Interview for Mental Status (BIMS) score of 14, no cognitive impairments.On 9/16/25 at 9:40 AM, Resident R23's window ledge was broken off, had sharp hard edges and had exposed wood. Heat from the outdoors could be felt through the broken area.Resident R23 stated she can feel the wind come through the window and the ledge had been broke since admission approximately nine months ago. Resident R23 stated her room would get cold in the wintertime due to the broken window ledge.On 9/18/25 at 11:30 AM, V20 (Maintenance Director) stated he was unaware of Resident R23's broken window ledge.

V20 stated the residents' rooms had been renovated and windows had been replaced over the past year or so. V20 agreed housekeeping, nursing staff or any other employee that provided care to Resident R23 should have identified and reported the broken window ledge.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Health Care Elms

3611 North Rochelle Peoria, IL 61604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to ensure weights were obtained and the physician was notified of weight gains per Physicians Order. The facility also failed to monitor weights for discrepancies for one of three residents (Resident R19) with daily weights in a sample of 28. Findings include:The facility's Weight policy, revised 5/18/25, documents the purpose of this policy is to monitor the residents' weights, and track weight changes as they occur.The facility's Documentation Guidelines policy, revised 3/14/17, documents, Not documented, not done, and document facts.Resident R19's Physician Order, dated 2/27/25, documents to weigh Resident R19 daily related to Resident R19's diagnosis of congestive heart failure and to notify the physician if Resident R19's weight gain is greater than three pounds (lbs.) in a day or five pounds in a week.Resident R19's Weight Summary, dated 6/1/25 to 9/17/25, has no documentation of Resident R19's daily weights being obtained for 28 out of the 59 days during the time span of 6/1/25 through 9/15/25. Resident R19's Weight Summary also documents daily weight gain fluctuations varying from 13.6 lbs to 36.9 lbs (6/21/25 through 6/22/25-36.9 lbs; 6/23/25 through 6/24/25-35.5 lbs; 7/10/25 through 7/11/25-32.6 lbs; 7/18/25 through 7/23/25 16.1 lbs; 8/22/25 through 8/23/25 13.6 lbs). Resident R19's current medical record has no documentation of Resident R19's physician being notified of Resident R19's weight gains of more than three pounds in a day and/or five pounds in a week.On 9/18/25 at 2:40 PM, V7 (Care Plan Coordinator) confirmed Resident R19's daily weights were not obtained as ordered, the physician was not notified of Resident R19's gains of more than three pounds in a day or five pounds in

a week per Resident R19's physicians order, nor were Resident R19's weights monitored for discrepancies.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Health Care Elms

3611 North Rochelle Peoria, IL 61604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

diagnoses: Multiple Sclerosis, Gastrostomy, Heart Failure, and endocarditis.

Level of Harm - Minimal harm or potential for actual harm

Resident R66's Physician's orders dated 8/5/25 documents, Enhanced Barrier Precautions.

Residents Affected - Few

On 9/17/25 at 11:41 AM V5 (Licensed Practical Nurse) performed hand hygiene and applied gloves. V5 assessed and gave water flush for Resident R66's feeding tube. V5 confirmed Resident R66 is on Enhanced Barrier Precautions (EBP). V5 then put gown on to finish Resident R66's cares.

On 9/17/25 at 12:40 PM V2 (Director of Nursing) provided Resident R66's urine culture results dated 9/7/25. Culture results document, Vancomycin screen is positive. This is VRE (Vancomycin Resistant Enterococcus).

On 9/17/25 at 12:45 PM V2 confirmed Resident R66's culture results indicate VRE. V2 stated, I went ahead and placed Resident R66 on contact isolation even though it is only two more days.

On 09/18/2025 at 9:15 AM V2 stated a physician's order is placed in the EHR (Electronic Health Record) when a resident is placed on contact isolation. V2 confirmed there was not a physician's order in Resident R66's chart for contact isolation at this time.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Health Care Elms

3611 North Rochelle Peoria, IL 61604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881

Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to maintain an Infection Control log for June, July, August and September of 2025. This failure has the potential to affect all 69 residents residing in the facility.Findings include:The facility's Resident Roster dated 9/16/25 was provided by V1/Administrator and documents 69 residents reside in the facility at the time of the survey.The facility's undated Infection Control Protocol and Antibiotic Stewardship policy documents, The Infection Control Preventionist/Antibiotic Stewardship Leader will track all Facility Infections, monthly laboratory organism reporting . On 9/18/25, V2 Infection Preventionist and DON/Director of Nursing could not provide a complete list of residents currently

on isolation precautions including Enhanced Barrier Precaution/EBP, Contact or Droplet isolation, or an Infection Control Log for June, July, August, or September 2025. On 9/16/25 at 2:45pm V2 stated she was

the facility's Infection Preventionist and produced the certificate of completion of the Infection Prevention Program Training dated 2023.On 9/17/25 at approximately 3:00pm V2 stated, she did not have Infection Control and tracking Logs for the months of June, July, August, or September of this year. V2 stated she knew the monthly tracking logs should have been completed in accordance with the Infection Control and Prevention Protocol and Infection Preventionist's role.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet