Timbercreek Rehab And Health Care Center

F 0580 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

of 8/4/25. V14 stated, I was told in report the day before (8/3/25) that (Resident R1) was having some pain. The next morning (8/4/25) the CNA (V16) called me in the room, and we couldn't really tell what was wrong. (Resident R1) was grabbing towards her right knee. We decided not to get her up or move her and that when dayshift comes in, they can order an x-ray. This was all before 6 AM, before we were going to change shifts. (Resident R1) kind of guarded her right knee. That morning with (V16), she had been more resistive to care. V14 confirmed she did not notify Resident R1's Physician (V7) or (V20, Resident R1's Guardian).Resident R1's nursing progress notes, dated 8/4/2025 at 11:03 AM and signed by V6 (Licensed Practical Nurse), documents Resident R1 was refusing all pain medications and was sent to the emergency department for evaluation and imaging. On 8/23/25 at 10:33 AM, V6 (Licensed Practical Nurse) stated, I took report on 8/4/25 (morning) and it was stated to me that (Resident R1) was acting strange towards the end of the night shift. I assessed (Resident R1) and when trying to assist her she recoiled and seemed fearful. I thought it could be her leg bothering her, but I wasn't sure. It was strange that (Resident R1) wasn't allowing staff to help her. That was new behavior for her. I was not aware of anyone notifying the (V7, Resident R1's Physician), (V20, Resident R1's Guardian), or (V2, Director of Nursing) prior to myself, that morning. Resident R1's Emergency Department notes, dated 8/4/25 at 2:34 PM and signed by V21 (emergency room doctor), documents Resident R1 was brought to the emergency room for right ankle swelling and later admitted to the hospital with a right closed Tibia-Fibula fracture and Dementia.On 8/23/25 at 12:10 PM, V2 (Director of Nursing) confirmed he was notified of the situation with Resident R1 on the date she was sent out to the hospital (8/4/25). V2 stated he was unaware she was having symptoms of pain the day prior (8/3/25). V2 confirmed when Resident R1 was sent to the emergency room it was discovered she had a lower right leg fracture of both bones and that V7 (Resident R1's Physician) and V20 (Resident R1's Guardian) was not notified of the change in Resident R1's condition until 8/4/25. The facility's Significant Condition Change and Notification policy, dated 12/2024, documents To ensure the resident's family and or representative and medical practitioner are notified of resident changes such as: A significant change in the resident's physical, mental or psychological status; Abnormal or unusual or new complaints of pain. This policy also documents When any of the situation exist,

the licensed nurse will contact the resident's representative and their medical practitioner. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day.

Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If the medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to

the emergency department. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. All significant changes will be recorded on the (facility's electronic record program) communication board in the resident record. Charting will include an assessment of the resident's current status as it relates to the change in condition.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Timbercreek Rehab and Health Care Center

2220 State Street Pekin, IL 61554

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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

psychological and physiological effects of unrelieved pain. Optimal management of the resident experiencing pain enhances the healing and promotes both physical and psychological wellness. It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain. Expressions of pain may be verbal or nonverbal and are subjective to the resident including but not limited to: negative verbalizations and vocalizations (groaning, crying, whimpering, screaming), behavior such as resisting care, distressed pacing, irritability, depressed mood or decreased participation in usual physical and/or social activities. If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident's care providers. Pain control mechanisms include but are not limited to: Medications administered for the control or relief of pain, Medications administered for the control or relief of anxiety, Repositioning of the resident. Management of the resident's pain is an interdisciplinary process, and it is to be included on the resident's interdisciplinary care plan.The facility's Controlled Substance policy, dated 12/2024, documents Controlled substances are subject to special handling, storage, disposal, and record-keeping requirements. The facility will maintain compliance with these special provisions. The licensed nurse or CMT (Certified Medication Technician) where applicable will sign the medication out on

the Controlled Substance Proof of use form immediately and will document the medication on the Medication Administration record immediately after administering the drug. The Controlled Substance Proof of use record is to be kept in the Controlled Medication Book. When completed, these records are to be placed in the resident's permanent record.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Timbercreek Rehab and Health Care Center

2220 State Street Pekin, IL 61554

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

a resident (Resident R1) on 15-minute watch right now. I have around 22 residents in my hall. Of those I have five to six (mechanical lifts) and that requires two staff members for every transfer. It can be very difficult to keep up with everything. On 8/23/25 at 10:33 AM, V6 (Licensed Practical Nurse) stated, We did just have some staffing cuts which makes it difficult at times to get things accomplished. Treatments and charting are things that often can't be caught up on. Especially charting. For example, that day (8/4/25) I had two residents transfer out to the hospital and it put me behind on everything else. It's hard to give safe resident care when you don't have enough staff in the building. The residents will often complain of longer wait times and that staff morale has decreased.On 8/22/25 at 3:20 PM, V2 (Director of Nursing) confirmed the facility is hearing more resident complaints on not having enough staff. V2 stated, Residents have complained to me about

the staffing cuts that were made. We also have increased our census so we are getting more residents and more behaviors/care needs and we are scaling back on staff. It is noticeable to residents and of course staff feel it too.The facility's Facility Assessment, dated 7/13/25, does not include numerical staffing requirements necessary of nurses and nursing assistants for each shift, to meet the needs of the residents based on the resident population and census. This same assessment documents, The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the (state minimum) staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs.The facility's (undated) Activities of Daily Living policy, documents, This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on

the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, communication including using speech, language or other functional communication systems specific to the needs of the individual resident.

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If continuation sheet