Sharon Health Care Pines

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on interview and record review, the facility failed to protect a resident from physical abuse for one of four residents (Resident R2) reviewed for abuse in a sample of 11. Findings include: The Abuse Prevention Program Facility Policy, revised 12/18/24, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This form also documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Instances of abuse of all residents, irrespective of

a mental or physical condition, cause physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behaviors through corporal punishment. Resident R2's Progress Notes, dated 8/6/25, documents that Resident R2 was involved in a physical altercation with a peer. Peer (Resident R10) pushed resident (Resident R2). (Resident R2) fell to the floor, landing on his left side. Resident R2's Brief Interview for Mental Status, dated 6/3/25 documents a score of 3, indicating that Resident R2 is cognitively impaired. Resident R2's current care plan documents that Resident R2 displays poor planning, poor insight, judgment, and decision-making ability, poor stress and emotion management, and poor impulse control. This form also documents that Resident R2 has reactionary responses to situations. Resident R2 reacts impulsively and without thought. Resident R10's Progress Notes, dated 8/6/25, documents that Resident R10 was involved in a physical altercation with a peer (Resident R2). (Resident R10) pushed (Resident R2), causing him to fall and land on his left side. Resident R10's Brief Interview for Mental Status, dated 6/9/25, documents a score of 15, indicating that Resident R10 is alert and oriented to person, place, and time. Resident R10's current care plan documents that Resident R10 has issues with regulating emotions and outbursts. Resident R10 can become verbally and physically aggressive. Resident R10 will initiate the conflict but will take responsibility for her own behavior. Resident R10's goal is not to harm self or others by the next review date and to seek out staff when agitated. On 8/22/25 at 11:30am, Resident R10 stated that Resident R2 was attempting to cut in front of her in line, so she pushed him away, and he fell. Resident R10 became agitated and started to yell out and curse during the interview. On 8/22/25 at 10:30am, V1, Administrator, verified that V18, Registered Nurse, did not notify him of the incident, so there were no interventions implemented. V1 also verified that an investigation was not started until today when notified of

the incident.

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:

14E322

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

14E322

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Health Care Pines

3614 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, the facility failed to report resident-to-resident physical abuse to the State Agency for one (Resident R2) of four residents reviewed for abuse in a sample of 11. Findings include: The facility's Abuse Prevention Program Facility Policy, dated 8/12/25, documents that employees are required to report any incident allegation or suspicion of potential abuse, neglect, exploitation, mistreatment misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of

the administrator, reporting can be made to an individual who has been designated to act as administrator

in the administrator's absence. This form also documents that when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Resident R2's Progress Notes, dated 8/6/25, documents that Resident R2 was involved in a physical altercation with a peer. Peer (Resident R10) pushed resident (Resident R2). (Resident R2) fell to the floor, landing on his left side. Resident R10's Progress Notes, dated 8/6/25, documents that Resident R10 was involved in a physical altercation with a peer (Resident R2). (Resident R10) pushed (Resident R2), causing him to fall and land on his left side. On 8/22/25 at 10:30am, V1, Administrator, verified that he was not notified of this incident, so no investigation or reporting was done.

Event ID:

Facility ID:

14E322

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

14E322

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sharon Health Care Pines

3614 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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to investigate resident-to-resident physical abuse for one of four residents (Resident R2) reviewed for abuse in a sample of 11. Findings include: The facility's Abuse Prevention Program Facility Policy, dated 8/12/25, documents that upon learning of the report of an allegation of abuse, the administrator or designee shall initiate an incident investigation. Resident R2's Progress Notes, dated 8/6/25, documents that Resident R2 was involved in a physical altercation with a peer. Peer (Resident R10) pushed resident (Resident R2). (Resident R2) fell to the floor, landing on his left side. Resident R10's Progress Notes, dated 8/6/25, documents that Resident R10 was involved in a physical altercation with a peer (Resident R2). (Resident R10) pushed (Resident R2), causing him to fall and land on his left side. On 8/22/25 at 10:30am, V1, Administrator, verified that he was not notified of this incident, so no investigation or reporting was done. V1 stated that any allegation or incident to supposed to be reported to him or V9 as soon as it happens. V1 also stated that an investigation is initiated immediately, even on weekends or after hours.

Residents Affected - Few

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

Event ID:

Facility ID:

14E322

If continuation sheet