Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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** Based on
observation, interview, and record review, the facility failed to transfer a resident with the required
mechanical lift, for one of three residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1
falling twice and during the second fall sustaining a periprosthetic distal left femur fracture, ongoing pain,
and psychosocial fear of being transferred with a mechanical lift.
FINDINGS INCLUDE:
The facility policy, Fall Policy and Procedure directs staff, 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 falling .Should the resident be observed sitting on the floor or being assisted by staff to sit down on the
floor, the nurse will be notified and a fall report will be completed
R1's current facility Face Sheet documents that R1 was admitted to the facility on [DATE] after a fall with a
Left Hip Fracture. This same form includes the following diagnoses: Cerebral Palsy, Blindness of One Eye,
History of Cerebral Infarction, Paraplegia, Depression with Psychotic Features and Anxiety.
R1's (current) Care Plan, dated 6/16/2023 includes the following Focus Areas: (R1) is at risk for falls related
to history of cerebral palsy, left hip fracture and left-sided paraplegia. Also included are the following
Interventions: Transfers: (R1) requires extensive assistance by two staff to move between surfaces using a
(mechanical) lift.
R1's Minimum Data Set Assessment, dated 11/14/2024 documents, ADL's (Activities of Daily Living):
Impairment on one side of lower extremity; requires use of wheel chair; requires substantial/max
(maximum) assistance for bathing, dressing, and bed mobility and is dependent for all transfers. Requires
extensive assistance of 2 staff members and (mechanical) lift for all transfers.
R1's Fall Risk Evaluation, dated 11/24/2024 documents, One to two falls past 3 months, Intermittent
confusion, Chairbound/Incontinent, 1-2 Predisposing Diseases, Gait/Balance- not able to perform function
and Takes 1-2 (High Risk) Medications. Risk For Falls: (R1) is at risk for falls.
R1's Nursing Progress Notes, dated 1/9/2025 at 3:51 P.M. document, CNA (Certified Nursing Assistant)
was behind (R1) holding (R1) at the shower bar while attempting to transfer from (R1's) w/c (wheelchair) to
the shower chair, for a shower. (R1) thought her phone had fell out of her belongings onto the floor and
turned around suddenly and fell on her buttocks. No apparent injury.
(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 3
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
02/10/2025
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 0689
Level of Harm - Actual harm
The facility Fall Investigation form, dated 1/9/2025 documents,(V5/Certified Nursing Assistant) was behind
(R1) holding her while (R1) held shower bar. (R1) jerked around and fell on her buttocks.
Recommendations/Interventions: Staff Member (V5/Certified Nursing Assistant) was educated on (correct)
transfer for (R1) and the use of a shower bed.
Residents Affected - Few
R1's Nursing Progress Notes, dated 1/24/2025 at 3:48 P.M. document, This Nurse (V4/Registered Nurse)
had a conversation with (V6/Certified Nursing Assistant) (who) stated (R1) only told me her leg hurt and
that (R1) didn't didn't know why. (V6/Certified Nursing Assistant) stated I transferred (R1) and (R1) started
shaking and buckled and I lowered (R1) to the floor. There was no fall, I lowered (R1) to the floor.
R1's Nursing Progress Notes, dated 1/24/2025 at 4:00 P.M. document, Certified Nursing Assistant came to
Nurses' Desk and (stated) (R1) needed something for pain. (Nurse) went to (R1's) room and asked (R1)
what was wrong and what hurt. (R1) stated her L (left) upper thigh hurt. (I) asked (R1) what type of pain,
aching, sharp and (R1) replied deep aching. (Nurse) gave (R1) (Acetaminophen) (Analgesic) at (3:50 P.M.).
R1's Nursing Progress Notes, dated 1/24/2025 at 6:41 (P.M.) document, Upon coming on shift,
(V4/Registered Nurse) reported that (V6/Certified Nursing Assistant/CNA) had lowered (R1) to the floor.
CNA indicated that (R1) is complaining of pain in the left leg, describing it as excruciating. (R1) also stated
that she is unable to move her left leg. Upon assessment, the nurse observed swelling to (R1's) right ankle.
The physician has been notified of the situation.
R1's Nursing Progress Notes, dated 1/24/2025 at 6:56 P.M. document, MD (Medical Doctor) states send
(R1) to the ER (Emergency Room). (R1) to be further evaluated.
The facility Fall Investigation form, dated 1/24/2025 documents, (R1) stated her left thigh hurt and she didn't
know why and (R1) had pain when nurse tried to lift her leg. Later, (V6/CNA) stated she transferred (R1)
and (R1) began shaking and buckled and (V6) lowered (R1) to the floor. Recommendations/Interventions:
(V6) was disciplined and all the other staff will be inserviced to use (mechanical) lift only with (R1).
R1's (hospital) History and Physical documents, admission date: 1/25/25. (R1) with past medical history for
depression with anxiety, seizure disorder, and left-sided hemiplegia due to cerebral palsy who presented to
the hospital after a fall at (facility). (R1) was reportedly being transferred by the staff when (R1) was
dropped, landing on her left side. Imaging in the ED (Emergency Department) showed questionable left hip
injury as well as a distal periprosthetic femur fracture on the left. (R1) reports significant discomfort in her
left leg at this time, more in the distal thigh but has some pain in the hip. ASSESSMENT AND PLAN:
Closed fracture of distal end of femur. Orthopedic surgery has been consulted.
On 2/10/2025 at 10:45 A.M., R1 was seated in a wheel chair in the (facility) Dining/Activity Room with other
residents, at a table for coffee and donuts. (R1) recalls falling two times, once when staff dropped me. R1
becomes visibly upset, crying when talking of incident. Repeats over and over, I hurt. I'm afraid of the lift.
Refused to answer further questions surrounding incidents.
On 2/10/2025 at 10:59 A.M., V4/Registered Nurse (RN) stated, I have been a nurse here for the past ten
years and three weeks. (R1) had a history of a previous fall with a fracture, left-sided paraplegia, and a
history of cerebral palsy. (R1) was supposed to be a two person, lift for all transfers.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146098
If continuation sheet
Page 2 of 3
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
02/10/2025
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 0689
Level of Harm - Actual harm
Residents Affected - Few
V6/Certified Nursing Assistant (CNA) came to me and asked if (R1) had anything for pain. (V6/CNA) said
(R1's) leg hurt. I went to see (R1) and she told me that (V6/CNA) had dropped her and hurt her leg. When I
questioned (V6/CNA), she told me she was transferring (R1) by herself from the bed to (R1's) wheelchair
and (R1's) leg buckled and (V6/CNA) lowered (R1) to the floor. (V6/CNA) kept repeating that she only
lowered (R1) to the floor. I didn't do a fall report right away, call the doctor, or R1's family or the DON
(V2/Director of Nurses). I didn't consider it a fall. It wasn't until later that (V2/DON) told all of us that even
when you lower someone to the floor, it's considered a fall. (R1) has always been a (mechanical) lift for all
transfers. (V6/CNA) should not have been trying to transfer (R1) by herself.
On 2/10/2025 at 12:25 P.M., V3/Care Plan Coordinator stated she was responsible for all the facility fall
investigations. States (R1) is at risk for falls due to history of CP (Cerebral Palsy), paraplegia and blindness
to (the) left side and history of falls with a fracture. States (R1) does not stand and has been a (mechanical)
lift for the past two years. States facility policy is for all mechanical lift transfers to be performed with two
staff members present. States (R1's) care plan addressed (R1's) interventions including the use of a
mechanical lift for all transfers. States (R1's) facility care cards, addressed (R1's) need for a mechanical lift
for all transfers. States care cards are used to inform the CNAs (Certified Nursing Assistants) what specific
care each resident requires. States she investigated both of (R1's) falls in January. States on 1/9/25 at 3:00
PM, (V5/CNA) was attempting to transfer (R1) by herself, without using a mechanical lift, from (R1's) wheel
chair to a shower chair. Confirmed that (R1) fell on her buttocks. States (V5/CNA) was educated on the
need to use a mechanical lift to transfer (R1) from her wheelchair onto the facility shower bed, for (R1) to
receive a shower. Also confirms that (R1) fell again on 1/24/25 at 3:40 PM when (V6/CNA) transferred (R1)
by herself, without the use of a mechanical lift from (R1's) bed to (R1's) wheelchair, when (R1's) leg gave
out and she lowered (R1) to the floor. States (V6/CNA) was disciplined for failure to use a mechanical lift
and another staff assistance for all of (R1's) transfers and all other nursing staff were educated on the need
to use a mechanical lift to transfer (R1).
On 2/10/2025 at 1:12 P.M., V5/Certified Nursing Assistant (CNA) confirmed on 1/9/25 she attempted to
transfer (R1) from the wheelchair to a shower chair, while in the shower room. (V5/CNA) states (R1)
thought she had dropped her phone and turned around suddenly to look for it and fell onto (R1's) buttocks.
(V5/CNA) states she didn't know she was supposed to transfer (R1) at all times with a mechanical lift,
states she hadn't worked with (R1) very often.
On 2/10/2025 at 1:18 P.M., V6/Certified Nursing Assistant verified on 1/24/25 she attempted to transfer (R1)
from the bed into (R1's) wheelchair, when (R1's) leg gave out and she lowered (R1) to the floor. (V6/CNA)
states she wasn't aware she was supposed to transfer (R1) with a mechanical lift and additional staff
assistance, at all times.
On 2/10/2025 at 1:26 P.M., V7 and V8/Certified Nursing Assistants prepared to transfer (R1) from the
wheelchair to bed for incontinence care via a mechanical lift. (R1) began yelling out and was tearful with
any movement of her left leg.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146098
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the February 10, 2025 survey of SHARON HEALTH CARE ELMS?
This was a inspection survey of SHARON HEALTH CARE ELMS on February 10, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SHARON HEALTH CARE ELMS on February 10, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.