Inspection·December 7, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to store all controlled medications (schedule II medications) in a secured locked box in the medication cart and failed to destroy all controlled medications once discontinued for four of four residents (R1, R2, R3, R4) reviewed for medication storage in the sample of four. Findings include: The facility's Schedule II Drug Inventory policy dated 03/2000 documents, Procedure: Maintain a declining inventory record by resident by drug on all schedule II drugs. Records must be accurate. Reconcile the declining inventory record at the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. Store all controlled drugs in a separate locked box within the medication cart. The facility's High-Alert Medications policy (undated) documents, When an opioid or narcotic medication is discontinued, it shall be destroyed in the presence of two nurses and a destruction log completed. Verification at shift turnover occurs when two nurses verify the accuracy of the control drug sheet for all narcotic medications until destroyed. 1. R1's Physician's Orders dated 11-3-23 document the following order: Tramadol HCL (Hydrochloride) 50 mg (milligrams) one tablet every six hours as needed for pain. R1's Progress Notes dated 11-21-23 document R1 expired on 11-21-23 at 5:05 AM. R1's Controlled Drug Receipt/Record/Disposition Form dated 11-3-23 (admission) to 11-21-23 (R1's) death documents R1 had 29 tablets of Tramadol HCL 50 mg left on the medication card on 11-21-23. 2. R2's Physician's Orders dated 8-16-23 to R2's Discharge (8-22-23) document the following order: Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every four hours as needed for pain. R2's Controlled Drug Receipt/Record/Disposition Form dated 8-16-23 to 8-22-23 (discharge) documents R2 had one tablet of Hydrocodone-Acetaminophen 5-325 mg left in the medication bottle on 8-22-23. 3. R3's Physician's Orders dated 10-30-23 documents the following order: Hydromorphone HCL (Hydrochloride) oral one mg/ml (milliliter) give five ml every three hours as needed for pain. Discontinue 11-19-23. (continued on next page) 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 Page 1 of 2 Event ID: 146098 Printed: 05/15/2026 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 146098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 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)