Timbercreek Rehab: Pain Management Failures Found - IL
The inspection, triggered by a complaint, found that residents identified as experiencing pain were not being reassessed at least once per shift and before and after every pain control attempt. The signs inspectors were told to watch for — groaning, crying, whimpering, screaming, resisting care, distressed pacing, depressed mood — were the baseline against which reassessment was supposed to be measured. That reassessment wasn't happening.
Pain management at the facility was supposed to be an interdisciplinary process, built into each resident's care plan. The tools available were straightforward: medications for pain, medications for anxiety, repositioning. Whether any of those were being deployed consistently, the inspection record does not say. What it does say is that the process for checking whether they worked was breaking down.
The controlled substance failures ran alongside the pain management problems. The facility's own policy, updated in December 2024, required nurses and certified medication technicians to sign out controlled substances on a Proof of Use form immediately after administering them, then record the administration on the medication record right away. Both steps were to happen without delay. The completed records were to be kept in the Controlled Medication Book and eventually filed in the resident's permanent record.
The inspection found the facility was not meeting those requirements.
The deficiencies were classified as causing minimal harm or the potential for actual harm, and few residents were affected. The complaint inspection was completed August 25, 2025.
For the residents who were groaning or crying or pacing their rooms in distress, the question the inspection leaves open is a simple one: how many shifts passed before anyone stopped to check whether the pain had gotten better or worse.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Timbercreek Rehab and Health Care Center in PEKIN, IL was cited for violations during a health inspection on August 25, 2025.
That reassessment wasn't happening.
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.