Health inspection·October 8, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R11's Face Sheet documents R11 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Personal History of Urinary Tract Infections, Constipation, Chronic Kidney Disease, Stage 2, and Type 2 Diabetes Mellitus. R11's Emergency Department to Hospital admission Report documents that R11 was sent to the hospital on 9/2/24 due to R11 not having urine output for three days. A bedside ultrasound showed 1500 cc/cubic centimeter of urine retained in R11's bladder. R11 was admitted to the hospital for Urinary Retention and Constipation. R11 discharged back to the facility on 9/5/24. R11's Census List printed 10/8/24 at 10:27 AM documents that R11 transferred out to the hospital on 9/2/24 and transferred in from the hospital on 9/5/24. There was no evidence in R11's medical record of a bed hold notification given to R11 or R11's representative for 9/2/24. 4. R46's Census List, dated 10/8/24, documents R46 discharged to the hospital on [DATE], 3/11/24 and 8/19/24. On 10/7/24 at 9:50 am, V4 (Minimum Data Set Nurse/MDS Nurse) stated, The nurses on the floor are supposed to be giving a Bed Hold Policy and written notification to the Residents when they go to the hospital. I cannot find any documentation of a bed hold being given to R6, R9, R11, and R46 for the dates above. On 10/8/24 at 10:00 am, V1 (Administrator) stated, I do not have any documentation or copies of bed holds for R6, R9, R11 or R46 for the dates above. On 10/8/24 at 10:40 am, V1 (Administrator) stated, I did find a few copies of signed written notifications for some of the Residents when they discharged , but we do not seem to have a specific routine on doing these. Surveyor: [NAME], [NAME] Based on interview and record review the facility failed to provide a bed hold notification to the resident or resident representative for four of four residents (R6, R9, R11, R46) reviewed for hospital transfers in the sample of 27. Findings include: Page 1 of 9 146098 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's Bed Reserve policy, undated, documents Notification Process: All residents will be provided notification of bed reserve policy upon admission. In addition, a copy of the policy will be provided upon hospitalization along with other pertinent documents. Responsible parties will be notified by phone of the bed reserve policy within 24 hours. 1. R6's Census List, dated 10/8/2024, documents R6 was discharged to the hospital on 3/6/24, 3/9/24, and 5/13/24. There was no evidence in R6's medical record of a bed hold notification given to R6 or R6's representative for 3/6/24, 3/9/24, and 5/13/24. 2. R9's Census List, dated 10/8/2024, documents R9 was discharged to the hospital on 7/9/24, 7/19/24, 9/8/24, 9/16/24, and 9/19/24. There was no evidence in R9's medical record of a bed hold notification given to R9 or R9's representative for 7/9/24, 7/19/24, 9/8/24, 9/16/24, and 9/19/24. 146098 Page 2 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a Care Plan for pain for one resident (R4) of 24 residents reviewed for pain in the sample of 27. Findings include: The Care Plan Policy dated 6/1/23 documents Residents admitted to the facility will have a care plan initiated within 48 hours of admission and completed no later than 21 days after admission. Care plans are revised at least quarterly, whenever there is a significant change in the patient's condition and on an as needed basis. Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patients plan of care. The development, implementation, and maintenance of a patient's plan of care is an interdisciplinary process. All disciplines involved in the care of a patient collaborate to develop the care plan. Each healthcare team member provides input based on comprehensive assessments. The patient/family/responsible party is included in the development, implementation, maintenance, planning and evaluation of the care provided. The patient goals and plan of action are updated by the individual who identified the problem area or by other healthcare team members according to their area of expertise. Multiple care team members may have input to and document on a plan of action for any health care concern. R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Muscle Wasting and Atrophy, Abnormal Posture, Presence of Right Artificial Hip Joint, Vascular Dementia, Severe, without Behavioral Disturbance, Age-Related Cognitive Decline, and Disorganized Schizophrenia. R4's Physician Order Summary printed 10/8/24 at 12:57 PM, documents that R4 takes Acetaminophen with Codeine 300-30 mg/milligrams two times a day for pain. Start date is 9/4/24 with no end date documented. R4's Care Plan printed 10/8/24 at 12:57 PM does not document a care plan for pain. On 10/8/24 at 11:58 AM, V4 (Minimum Data Set/Care Plan Coordinator) stated that R4 does not have a care plan for pain. On 10/8/24 at 2:20 PM, V2/Director of Nursing stated that R4 takes scheduled Tylenol with Codeine twice a day for lower back pain and general body pain. R4 has taken the medication about a month and there is not a care plan for R4's pain. V4 does the care plans and there was a communication problem that caused V4 not to know that R4 needed to have a pain care plan. 146098 Page 3 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.) On 10/7/24 at 9:15 AM, R40 was sitting in front of the facility in his wheelchair with two other residents and had just finished smoking a cigarette. There were no staff present for supervision. On 10/8/24 at 11:55 AM, V4/MDS/Minimum Data Set Coordinator stated that R40 is an independent smoker and does not need to be monitored. On 10/8/24 at 2:20 PM, V2/Director of Nursing stated that the smoking assessments are to be done at least yearly by V14/Activity Director. R40's Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Mild Cognitive Impairment, Emphysema, and Chronic Obstructive Pulmonary Disease. R40's Care Plan dated 3/23/22 documents (R40) is an independent smoker. The Resident Smoking List for October 2024 documents that R40 is an independent smoker. R40's facility Smoking -Safety Screen dated 3/1/23 at 3:23 PM, documents that R40 has cognition loss, dexterity problems, is an independent smoker, keeps his own smoking materials, and lights his own cigarettes. The Smoking Safety Policy and Procedure revised 7/18/2019 documents Policy In order to provide the residents of (the facility) the opportunity to use tobacco products and do so in a safe environment and manner, the following procedures/rules/regulations shall be followed by all residents. Procedure Those that wish to use tobacco products will be assessed upon admission, yearly, and as needed as to the resident ability to smoke safely and to ascertain other needs the resident may have in which using tobacco products would be an issue, i.e. (example), ability to manage/ budget tobacco products. Based upon this assessment the resident will be placed in one of three groups as described below (full independence, managed independence, or supervised). A copy of the rules and regulations pertaining to smoking is given to each resident and further discussed with the SSA (Social Service Assistant). A Smoking Contract is then executed indicating the resident's understanding of smoking rules and his/her agree compliance. 2. R8's Fall Investigation Worksheet/Worksheet, dated 5/25/24 at 8:56 pm, documents that R8 slid out of the wheelchair in R8's room, while transferring self to bed. The Worksheet documents no injuries and fall interventions for a gripper pad to be placed in R8's wheelchair and to utilize a nightlight. R8's Fall Investigation Worksheet, dated 7/1/24 at 4:00 pm, documents a fall in R8's bathroom. The Worksheet documents that R8's decision making is impaired and has unsteady gait. The Worksheet describes that R8 hit the side of R8's head on R8's bathroom door jamb/frame while trying to get up from the toilet. The Worksheet documents no injuries and fall interventions for staff to intervene when they see her going down the hall and ask her is she needs to go to the bathroom and take her as much as possible. 146098 Page 4 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0689 Level of Harm - Actual harm R8's Fall Investigation Worksheet, dated 7/27/24 at 3:00 pm, documents a fall from R8's wheelchair, in R8's room. The Worksheet documents that R8 has impaired memory, impaired decision making and is impaired physically. The Worksheet documents no injuries and fall interventions to educate R8 on the proper use of R8's call light. Residents Affected - Few R8's Fall Investigation Worksheet, dated 9/8/24 at 10:08 am, documents a fall from R8's wheelchair in R8's room. The Worksheet documents no injuries and that R8's gripper pad be replaced in R8's wheelchair. On 10/8/24 at 12:50 pm, V2 (Director of Nursing) stated (R8) is confused and self transfers a lot. (R8) is frequently taking herself to the bathroom and she always slides to the end of R8's wheelchair seat all the time too. On the first fall, we put a gripper pad on (R8's) wheelchair to help to grip (R8) in the wheelchair but (R8) does not like it on there and removes it all the time. R8's MDS (Minimum Data Set) documents that (R8's) cognition score is ten out of fifteen, which is moderately impaired. We have educated (R8) and we just changed (R8's) gripper pad again. Now that I think about it, we probably should use some different interventions since (R8) is confused and keeps removing the gripper pad from (R8's) wheelchair. We do not have (R8) on a toileting schedule. Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to conduct a resident assessment to determine the resident's degree of mobility, physical impairment and the proper transfer method needed once a resident experienced increased weakness. The facility also failed to maintain an adequate working electrical supply to adjust an electric bed into the lowest position prior to a transfer for one resident (R9) and failed to implement appropriate fall interventions for one resident (R8.) These failures affect two of three residents (R8, R9) reviewed for falls in the sample of 27. These failures resulted in R9 losing grip of the sit-to-stand mechanical lift handles and falling to the floor, sustaining a coccyx fracture and severe pain that required hospitalization. B. Based on observation, interview, and record review the facility failed to assess the smoking safety yearly for one of five residents (R40) reviewed for smoking in the sample of 27. Findings include: a.) The facility's Job Description for CNA's (Certified Nursing Assistants), undated, documents Illustrative Examples of Work: Care delivery to include, but not limited to: Bathing a minimum of two times weekly, daily oral hygiene, shaving, changing clothes, nail care, toileting feeding, ambulating, transferring, room care, hair care. Recognizing and reporting changes in condition to the nurse (example: health problems, eating problems, changes in skin or incontinence behavioral problems, unstable vital signs.) Maintain a safe environment for the residents and other staff. Follow safety practices (example: keeping resident areas hazard free, follow good body mechanics, wear proper footwear, use lifting devices according to manufacturer's directs, wear gait belt, etcetera.). General Employee Guidelines: Immediately report defective equipment, hazardous conditions, or supply shortages. The facility's Fall Policy and Procedure, dated 1/2/2019, documents It is the Policy of (the facility) to provide an environment conducive to reducing risk for falls. (The facility) provides interventions to reduce risk factors for filling but cannot guarantee or maintain a fall-free environment. The facility's Transfer Between Surfaces policy, dated 3/2000, documents Purpose: To improve or 146098 Page 5 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0689 Level of Harm - Actual harm Residents Affected - Few maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. Procedure: 1. Explain and demonstrate procedure. 5. Bed should be flat and level with wheelchair seat. The facility's Fall Prevention Practice, dated 1/10/2016, documents Below is a list of things that can help reduce the risk for falls: 8. Report changes in mental status to nurse immediately. 1. R9's admission Record documents R9 is a [AGE] year-old male admitted to (the facility) on 5/14/2012 with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Difficulty in walking, Frontotemporal Neurocognitive Disorder, Dementia, Schizoaffective Disorder, Extrapyramidal and Movement Disorder, and Cerebral Infarction. R9's Minimum Data Set (MDS) assessment dated [DATE], documents R9 has severe cognitive impairment, and requires substantial assistance for activities of daily living, toileting, and transfers. R9's current Care Plan documents, (R9) has the potential for falls due to increased weakness. The facility's Maintenance Work Order dated 9/19/24 and signed by V7/CNA, documents R9's room had no electricity. R9's Progress Note, dated 9/19/24 and signed by V15/RN (Registered Nurse), documents (R9) was observed on the floor, lying on right side. Per two aides (Identified as V8/CNA (Certified Nursing Assistant) and (V9/CNA), they were attempting to get (R9) into bed. After a couple minutes, it was indicated that (R9) was to be moved back into chair due to the bed being unavailable for use. Throughout all of this, (R9) was in a mechanical stand lift and was already up at the highest position. Per (V8 and V9), (R9) began to drift down. (V8 and V9) stated that they pulled chair under (R9) but at that point (R9) was too low to get into his chair. Then (V8 and V9) stated that (R9) quickly slid through the straps due to him lifting his arms up, where (R9) then hit the floor at fast and unexpected speed where (V8 and V9) were unable to slowly lower (R9). Different reports of if (R9) hit head or not, so per the physician, we (the facility) called emergency services to send (R9) out to the emergency room to be evaluated due to nature of fall. Per (V8 and V9) (R9) was lethargic. No signs of lethargy when this nurse assessed (R9). During assessment, (R9) stated that he was in extreme pain on right side of arm. R9's Electronic Medical Record does not include evidence of a nursing assessment being performed when R9 was lethargic prior to be transferred from the wheelchair. R9's Local Emergency Record, dated 9/19/24, documents CT (Computed Tomography) pelvis for bone detail without contrast final result: Impression:1. Acute or subacute mildly displaced comminuted inferior coccyx fracture. This same form documents Clinical Impression: Fall, Urinary Tract Infection, and Hyponatremia (low sodium level.) On 10/06/24 at 9:02 AM R9 was in self-propelling wheelchair around R9's room. R9 had nonskid socks on. R9 was unable to answer questions appropriately at this time. On 10/7/24 at 12:04 PM V8/CNA stated, (V9/CNA) and I were transferring (R9) from his wheelchair to the bed with a mechanical stand lift machine. (R9) was weak when (V9) and I were lifting him, so (V9) and I tried to get (R9) to the bed quickly. When (V9) and I attempted to transfer (R9) to the bed we realized the bed was too high. I then tried to use the controller to lower the bed while (R9) was 146098 Page 6 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0689 Level of Harm - Actual harm Residents Affected - Few trying to hold on and slipping from the sit-to-stand machine at the same time. I realized the controller was not working to the bed, so (V9) and I attempted to turn him back around and put him in the wheelchair. By that time (R9) had let go of the sit-to stand and had fell to the ground. V8 verified at this time, that she should have not attempted to transfer (V8) when she realized he was weak and should have ensured the bed was working and in the proper position prior to transferring R9. On 10/7/24 at 12:14 PM V9/CNA stated, (R9) was not a resident on my group the night of 9/19/24, but I was asked to help lay (R9) down. (R9) had been outside at a party, and when he came inside, (R9) was found lopped over the side of his wheelchair in the television room. (V15/RN) called (V8/CNA) and I up to the nurse's desk and asked for us to lay (R9) down. I pushed (R9) to his room with (V8). I asked (V8) how she wanted to transfer (R9) since (R9) seemed weak and was lopped over. (V8) just stated we would transfer (R9) with the stand mechanical lift and get him to his bed. (V8) and I strapped (R9) to the mechanical stand lift machine and started lifting (V8) up in the air. As (V8) and I were lifting him up, (R9) started slipping and was barely hanging on to the (stand lift machine.) (V8) and I attempted to hurry and put (R9) in bed before (R9) fell just to notice the bed was too high. (V8) and I tried to use the controller to lower the bed and the controller wasn't working. (V8) and I attempted to turn (R9) back around to get (R9) in his wheelchair, but (R9) kept getting lower and lower and then let go of the (hand bars of the mechanical stand lift) machine. When (R9) let go of the (stand lift machine) (R9) fell quickly to the ground. If (R9) was on my group that night, I would have not transferred him to the bed when he was visibly weak. I would have gone and notified (R9's) nurse to have (R9) assessed. I should have done that anyway, but I felt like that was (V8's) responsibility. V9 verified she should have notified R9's nurse prior to transferring R9 when R9 was lethargic and should have ensured the bed was working and in the proper position prior to transferring R9 to the bed. On 10/7/2024 at 12:30 PM V6/Maintenance Assistant stated, I get work orders for no electricity all the time for rooms. The staff will move the resident's beds and hit the plug, which breaks a prong off in the outlet. When the staff went to plug the bed back in, the plug-in hits the prong and blows the circuit breaker. I received the work order for (R9) not having electricity in his room on 9/20/24. The staff laid it on my desk on 9/19/24, but I don't usually get to work orders in the same day, it's always the next day I am at the facility. No staff member got ahold of me to let me know (R9) did not have electricity in his room on 9/19/24. On 10/7/24 at 12:47 PM V7/CNA stated, I filled out a work order on 9/19/24 around 2:30 PM regarding (R9) not having electricity in his room. (R9's) television was not working. I put the work order on (V6/Maintenance Assistance) desk. I did not tell anyone else or try to get ahold of (V6) to fix it right then. On 10/8/24 at 1PM V2/Director of Nursing stated, If any staff notices a change in condition with a resident, they should immediately notify the nurse prior to transferring especially if the resident seems weaker. Also, the staff should have everything positioned correctly prior to transferring any resident. V2 verified no nursing assessment had been performed prior to V8/CNA and V9/CNA transferring R9 from his wheelchair. On 10/8/24 at 1:09 PM V3/Assistant Director of Nursing stated Staff should go to the nurse or myself prior to transferring a resident if they notice a change in the resident's condition or if they notice the resident is weaker. They should never transfer someone to a bed with the bed in high position, they should always ensure the bed is at appropriate position prior to transferring. 146098 Page 7 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide monitoring and documentation of dialysis access site observations, failed to provide communication with the dialysis center, failed to identify type of dialysis access site/device, failed to provide a current/valid dialysis contract and failed to develop and implement a policy and procedure for residents receiving offsite dialysis for one resident (R60) of one resident reviewed for Hemodialysis in the sample of 27. Residents Affected - Few Findings include: No Policy and Procedure for the care of a Dialysis resident residing at the facility was provided during the survey. On 10/6/24 at 10:30am V1, Administrator confirmed only one resident (R60) in the facility received dialysis. R60's Current Physician Orders indicate R60 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Cardiac Arrest and Diabetes Mellitus. R60's orders include One time a day every Monday, Wednesday and Friday related to End Stage Renal disease. R60's orders do not include dialysis or details including the type of dialysis R60 was to receive (on Monday, Wednesday, Friday). R60's Comprehensive assessment dated [DATE] indicates R60 is alert and fully oriented to persons, time, and situations. On 10/6/24 at 10:15am R60 was sitting in his room and refused to speak about anything. At that time, a large visible dialysis access device was visible in R60's left arm. R60 did acknowledge that the shunt in his left arm was for dialysis and responded Nobody does anything here when asked about how the nurses care for his access site. On 10/8/24 at 11:45am V10, RN (Registered Nurse) stated they do not send any type of communication sheet to dialysis with R60 or receive anything back. V10 stated We don't keep any type of communication sheets or have a dialysis communication book. They might let us know about labs or something if we need to know. On 10/8/24 at 11:50am V11, RN (R60's assigned nurse) and V12, LPN (Licensed Practical Nurse) stated there were no dialysis communication sheets for R20. Both V11 and V12 stated they check R60's shunt for bruit and thrill and identified R60's shunt in left arm. V12 stated We have to put Lidocaine (topical anesthetic) on his arm before he leaves. No physician orders or instructions from dialysis were found or presented to indicate Lidocaine was to be applied to R60's arm. Review of R60's MAR/TAR's (Medication and Treatment Administration Records) from admission 8/19/24 through 10/8/24 did not document monitoring of R60's dialysis access device or checking for bruit and thrill. R60's current Care Plan indicates (date initiated 8/26/24): R60 goes to dialysis on Monday, 146098 Page 8 of 9 146098 10/08/2024 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Wednesday and Friday related to renal failure. R60 will have immediate intervention should any signs/symptoms of complications from dialysis occur through the review date. R60 will have no signs/symptoms of complications from dialysis through the review date. Check and change dressing daily at access site. Document. Do not draw blood or take Blood Pressure in arm with graft. Encourage R60 to go for the scheduled dialysis appointments. R60 receives dialysis 3 times a week. Monitor labs and report to doctor as needed. R60's Care Plan does not indicate location of dialysis access device, specific complications, or interventions to monitor or provision of medications on dialysis days. R60's MAR/TAR's (Medication and Treatment Administration Records) from admission 8/19/24 through 10/8/24 did not document monitoring of R60's dialysis access device. R60's Progress Notes from admission 8/19/24 to 10/8/24 did not document monitoring of R60's shunt pre or post dialysis. On 10/9/24 at 9:26am V1, Administrator stated before R60, they had not had a dialysis resident for a long time. V1 stated she was aware the Dialysis Contract provided during the survey was not the current Company that was providing dialysis for R60. V1 stated they need to review the requirements to care for a resident with dialysis. V1 acknowledged they did not have the necessary communication with dialysis, a valid dialysis contract or policy and procedure for caring for a dialysis resident. The dialysis contract provided by the facility was dated 2001/2007 and was not the contract for the company currently providing dialysis to R60. On 10/9/24 at 9:26am V1 confirmed she was still waiting for the current dialysis company to send a contract for her to sign. 146098 Page 9 of 9