Health inspection·February 26, 2026

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 act quickly to get medical care for one (R1) of three residents reviewed for injuries in a sample of four. This failure resulted in R1 continuing to be in pain at the nursing home after an incident that caused facial and body bruising for four and a half hours before the emergency personnel were summoned to the nursing home.Findings include: Facility Change of Condition Policy and Procedure, undated, documents The Facility shall promptly notify the resident his/her attending physician of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or on-call physician when there has been: An accidents or incident involving the resident; A discovery of injuries of an unknown source; and A need to transfer the resident to a hospital /treatment center.Facility medical record for R1 documents R1 was sent to the (local) hospital on 2/24/26.Facility Nursing Note for R1, dated 2/24/2026 at 8:21AM by V5 RN/Registered Nurse, documents the following: This nurse observed (R1's) bruised and swollen area on her L cheek and dried blood on her teeth and L lip. It hurts her to open her mouth, and she was unable to take her medicine. There is a light bruise on her L clavicle and a small bruised know above her L eye. Ice applied to L cheek.Facility Nursing Note for R1, dated 2/24/2026 at 9:20AM by V4 RN Wound Nurse documents the following: Several bruises noted on assessment this morning per nursing staff. On assessment, this RN observed bruising to the resident's right anterior shoulder, left anterior shoulder, left lateral head, forehead, left eyelid, left eyebrow, left cheek, left inner ear, left jaw, anterior neck, left upper chest, right dorsal hand, left 1st knuckle, left medial wrist, and top lip.Facility Nursing Note for R1, dated 2/24/2026 at 11:37AM by V5 RN, documents the following: Per (V13 R1's Physician) physician order, (R1) is to be sent to (local) Hospital for evaluation of facial and clavicle trauma.Ambulance Transport notes for R1, dated 2/24/2026 at 11:59AM, documents the following: Patient relayed that her face and neck are hurting. Hematoma (bruise) center of her forehead. Bruising above patients left ear. Left facial swelling and bruising. Dried blood noted on patients' teeth. Bruising noted on patients' anterior neck and left side. Bruising noted on patients left clavicle.R1's hospital record, dated 2/24/26 at 12:26PM by V4 RN, documents Fall (Nursing home) noticed some bruising in the face and dried blood in the mouth and pain with movement in face and neck.On 2/25/26 at 1:45PM, V5 RN/Registered Nurse stated she took care of R1 on 2/24/26 from 6AM to 6:30PM. Stated she saw her when passing medications around 7:30AM when she was in the dining room. When she saw R1 she was in the dining room and had dried blood on the left side of her lip and on her teeth; and R1 told her it hurt to open her mouth, so she refused her medications that were crushed in pudding. (V11) Certified Nurse Aid/CNA had asked me about 7AM if I had seen (R1's) cheek and I told her I had not. I saw her raised bruised left cheek about the size of a quarter; and she had a raised bruise above her left eye about a dime size. The bruises were grey. She also had a knot on her forehead and a bruise to her left clavicle that was grey. I put ice on R1's left cheek and notified (V2) RN DON/Director of Nursing. Then (V2) spoke to (V13/R1's) doctor to Residents Affected - Few Page 1 of 4 146098 146098 02/26/2026 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0684 get the order to send her out. I did not send R1 out right away, there was a delay in her going to the hospital, and she was sent out about lunch time (noon). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146098 Page 2 of 4 146098 02/26/2026 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to follow their policy for reducing falls and using a portable lifting machine for one (R1) of three residents reviewed for accident/incidents in a sample of four. This failure resulted in R1 sustaining multiple bruises to her face and body, and pain which required R1 to be transferred to the hospital.Findings include: Facility Using a Portable Lifting Machine, dated May 2008, documents The primary purpose of using a portable lifting machine is to help lift residents who may be too heavy to lift. The portable lift is also used to promote comfort and to maintain good body alignment while the resident is being moved. This procedure requires the assistance of two (2) persons.Facility Fall Policy and Procedure, revised 1/2/2019, documents It is the Policy of (nursing home) to provide an environment conducive to reducing risk for falls. (Nursing home) provides interventions to reduce risk factors for falling.Facility medical record for R1 documents R1 was sent to the (local) hospital on 2/24/26. Facility Mobility Assessment for R1, dated 1/13/2026, documents the following: Surface-to-surface transfer (transfer between bed and chair or wheelchair) not steady, only able to stabilize with staff assistance. Extensive assistance with bed mobility. Total dependence on transferring. Transfer support needed two plus person's physical assist.Facility Nursing Note for R1, dated 2/24/2026 at 8:21AM by V5 RN/Registered Nurse documents the following: This Nurse observed (R1's) bruised and swollen area on her L cheek and dried blood on her teeth and L lip. It hurts her to open her mouth, and she was unable to take her medicine. There is a light bruise on her L clavicle and a small bruised know above her L eye. Ice applied to L cheek.Facility Nursing Note for R1, dated 2/24/26 at 9:20AM by V7 RN Wound Nurse, documents the following: Several bruises noted on assessment this morning per nursing staff. On assessment (R1), this RN observed bruising to the resident's right anterior shoulder, left anterior shoulder, left lateral head, forehead, left eyelid, left eyebrow, left cheek, left inner ear, left jaw, anterior neck, left upper chest, right dorsal hand, left 1st knuckle, left medial wrist, and top lip. Facility Nursing Note for R1, dated 2/24/2026 at 11:37AM by V5 RN, documents the following: (R1) was sent to (local) Hospital for evaluation of facial and clavicle trauma.Ambulance Transport notes for R1, dated 2/24/2026 at 11:59AM, documents the following: Patient relayed that her face and neck are hurting. Hematoma (bruise) center of her forehead. Bruising above patients left ear. Left facial swelling and bruising. Dried blood noted on patients' teeth. Bruising noted on patients' anterior neck and left side. Bruising noted on patients left clavicle.Hospital Nursing Note for R1, dated 2/24/26 at 12:26PM by V4 RN, documents the following: Fall- Nursing home noticed some bruising in the face and dried blood in the mouth, dementia baseline, has bruising in different stages of healing, and pain with movement in face and neck. Bruising in the left clavicle.Hospital Note for R1, dated 2/24/26 at 12:26PM by V14 Physicians Assistant, documents the following: Dried blood in the oropharynx (mouth). Superficial abrasions are appreciated to the internal lips with a large laceration. Pain with palpation to the right elbow, right scapula, left clavicle, superior left orbit, left forehead, and midline cervical spine. Bruising most prominent to the right elbow, and right forearm with bruising consistent with thumb/finger as the cause. Ecchymosis (bruising) also noted to left clavicle, and anterior neck soft tissues. Large hematoma (lump) noted to the left forehead. Ecchymosis appreciated to the left upper orbit/eyelid.R1's hospital Cat Scan, dated 2/24/26 at 3:34PM, documents the following: The patient has pain with movement of the face and neck.On 2/25/2026 at 11:26 AM, V4 Hospital RN stated the following: V4 stated she was the nurse who was caring for R1 when R1 came into the emergency room. V4 stated R1 had a C-Collar (cervical collar) on, and it was on R1 in a manner that looked uncomfortable. V4 stated R1 had visible bruises on the top of her neck on the left side that 146098 Page 3 of 4 146098 02/26/2026 Sharon Health Care Elms 3611 North Rochelle Peoria, IL 61604

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a triangle area of spotted bruise that was dark purple and red. R1 had a knot on her left forehead the size of a dime, and a knot on the left cheek the size of a quarter. R1's left arm had purple/red bruising.On 2/25/26 at 10:45AM, V2 RN DON/Director of Nursing stated (R1) had a cracked lip with dried blood on it. She had bruises on her face and chest. There was a full body assessment done by our wound nurse where she had bruising to her neck, numerous areas to her left arm, chest and face. The bruising appeared fresh where some of the bruising was not noticed at first, it was like it was just evolving. She transfers with (portable lifting machine).On 2/25/26 at 1PM, V1 Administrator stated she fired V6 CNA/Certified Nurse Aid for transferring R1 with (portable lifting machine) by herself. Their policy for the (portable lifting machine) is to transfer with two people. Our policy for lifts (portable lifting machine) are always for two people. They (staff) have had a lot of education on this and you are automatically fired because we have drilled this into them with training.On 2/25/26 at 1:45PM, V5 RN stated she works 6AM to 6:30PM, and verified she worked 2/24/26 and was R1's nurse. V5 stated she saw R1 when passing medications around 7:30AM when she was in the dining room. When V5 saw R1, R1 had dried blood on the left side of her lip and on her teeth. R1 told her it hurt to open her mouth, so she refused her medications that were crushed in pudding. I saw her raised bruised on her left cheek about the size of a quarter, and she had a raised bruise above her left eye about a dime size. The bruises were grey. She also had a knot on her forehead and a bruise on her left clavicle that was grey. I put ice on R1's left cheek and notified our (V2).On 2/26/25 at 1:20PM, V6 CNA returned a phone call and stated I worked on 2/24/26 and took care of (R1), and I was terminated this morning for transferring (R1) with a (portable lifting machine) with only one person. We are supposed to use two people with the (portable lifting machine) but I transfer by myself all the time because I don't like to ask for help. (R1) had bruising on her left neck. I transferred her into her wheelchair (manual).On 2/26/26 at 2:28PM, V3 CNA stated, I worked 2/24/26 during the day and I was on (R1's) right side and saw blood in her mouth when she was talking, it was fresh blood because it was not dried.On 2/26/26 at 1:45PM, V11 CNA stated I worked 2/24/26 and when I went into R1's) room, I saw blood first on her mouth and then saw the bump on her left cheek in the dining room around 7:30AM but I did not see it before when in her room. Her injuries look to be in line with a fall.On 2/26/26 at 2:30PM, facility video footage was viewed on V1 Administrator's computer in her office. The video dated 2/24/26 at 6:59AM was viewed and the following was observed: 6:59AM V6 is observed wheeling the (portable lifting machine) into R1's room; 7:01AM R1's door was closed; 7:07AM R1's door was opened; 7:10AM R1's door is slammed shut; 7:15AM R1's door opens and the (portable lifting machine) is put in the doorway of R1's room by V6 and V6 went out of R1's room; 7:17AM V6 went back into R1's room with V3 and V11 both CNA's; and 7:20AM R1's door opens and R1 is pushed down the hallway in her wheelchair by V6 CNA. At that same time, you can see on R1's left side of her cheek a red area.On 2/26/26 at 2:30PM, V2 RN DON stated (R1's) injuries are consistent with a fall. I am not sure why staff was not helping (V6 CNA) with (R1) because on the video it shows staff sitting down on their phone outside of the room and not helping. We are 99.99% sure (R1) was dropped by (V6 CNA) because her injuries on her left side are consistent with a fall.On 2/26/26 at 2:40PM, V13 R1's Physician and Medical Director stated (R1's) injuries are consistent with a fall where they are all on her left side.On 2/26/26 at 3:04PM, V7 RN Wound Nurse stated (R1) had fresh bruising to the left side of her forehead, face, neck, ear, eyebrow, shoulder front and back, and knuckles. It was light blue bruising, so it was fresh. (R1) is solid in her body and weight and when we transferred her out it took four of us to move her. It appears she fell or hit her face/body into the (portable lifting machine) frame. 146098 Page 4 of 4