Timbercreek Rehab: Broken Leg Went Unreported Overnight - IL
By the time she reached the emergency room on the afternoon of August 4, 2025, she had fractures in both bones of her lower right leg.
The night shift nurse, identified in inspection records as V14, knew the resident had been in pain the day before. A nursing assistant had pulled V14 into the room before 6 AM after the resident started grabbing toward her right knee and resisting care. V14 made a decision. "We decided not to get her up or move her," V14 told inspectors, "and that when dayshift comes in, they can order an x-ray."
V14 confirmed she did not call the resident's physician. She did not call the resident's guardian. She waited for the shift to change.
The morning nurse, a licensed practical nurse identified as V6, took over and found the same thing: a resident who recoiled when staff tried to help her, showing fear that was new. "It was strange that she wasn't allowing staff to help her," V6 told inspectors on August 23. "That was new behavior for her." V6 said she thought it could be the resident's leg but wasn't sure.
V6 was not aware that anyone had called the physician, the guardian, or the Director of Nursing before she arrived that morning. She was the one who eventually sent the resident to the emergency room.
The ER doctor's notes, signed at 2:34 PM on August 4, documented right ankle swelling. The resident was admitted to the hospital with a right closed tibia-fibula fracture and dementia.
The Director of Nursing, V2, told inspectors he learned about the situation on August 4, the day the resident was sent out. He said he had no idea she had been showing signs of pain the day before, on August 3. He confirmed that the physician and the guardian were not notified of any change in her condition until August 4.
The facility's own notification policy, dated December 2024, lists abnormal or new complaints of pain as a condition requiring nurses to contact both the resident's representative and their medical practitioner. It states that non-emergency notifications may wait until the next morning if something happens on the night shift, but it also states that any emergency requires an immediate call regardless of the time of day, including holidays.
A resident grabbing at her knee, resisting all care, showing new fear of staff touching her: V14 classified that as something the next shift could handle.
The inspection, completed August 25, 2025, cited the deficiency at a level of actual harm.
What the record does not contain is any notation from the night of August 3 or the early hours of August 4 documenting an attempt to reach the physician. No time of call. No name of who was spoken to. No record that anyone tried.
The resident had dementia. She could not call anyone herself. She could not explain what had happened to her leg, or when, or how much it hurt. She could grab toward her knee and pull away from the people trying to move her.
That was all she could do. And for hours, it was enough for the staff around her to decide to wait.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timbercreek Rehab and Health Care Center from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Timbercreek Rehab and Health Care Center in PEKIN, IL was cited for violations during a health inspection on August 25, 2025.
By the time she reached the emergency room on the afternoon of August 4, 2025, she had fractures in both bones of her lower right leg.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.