Inspection·October 4, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on interview and record review, the facility failed to assess a wound and promptly initiate treatment upon identification of pressure ulcer for one of three residents (R2) reviewed for pressure ulcer wound treatment in the sample of eleven. This failure resulted in R2's pressure ulcer worsening to Unstageable. Residents Affected - Few Findings include: Facility's Decubitus Care/Pressure Area Policy Revised 1/2018 documents: 2. The pressure area will be assessed and documented on the Treatment Administration Record/TAR or the Wound Documentation Record. 3. Complete all areas of the Treatment Administration Record or Wound Documentation Record. I) Document size, stage, depth, drainage, color, odor, and treatment (upon obtaining from the physician); 4) Notify the physician for treatment orders. R2's Face Sheet documents R2's diagnoses include: Cerebral infarction, aphasia, weakness, metabolic encephalopathy, myocardial infarction type, atherosclerotic heart disease, essential hypertension, hyperlipidemia, type 2 diabetes mellitus. R2's current Care Plan documents: (R2) is at risk for impaired skin integrity including skin tears, bruising and/or pressure related to very limited mobility, inadequate nutrition, and problems with friction and shearing of skin due to needing maximum assistance for moving and changing position. R2's Braden Scale for Predicting Pressure Ulcer Risk Dated 6/22/24 documents a score of 13 (16 and less = High Risk for developing pressure ulcers). R2's Progress Note Dated 8/8/24 documents: Quality Assurance/QA team reviewed (R2's) new pressure ulcer to coccyx. Nurse reported new open pressure ulcer to coccyx on 8/4/24. On 10/2/24 at 9:10am, V7 Licensed Practical Nurse/LPN stated she was the nurse for R2 on 8/4/24 and noted R2's coccyx wound. R2's Physician Orders Dated 8/2024 has no documentation of a physician ordered treatment obtained upon identification of R2's wound on 8/4/24. R2's Treatment Administration Record/TAR did not contain documentation that wound treatments were performed on 8/4/24 or 8/5/24. On 10/2/24 at 9:30am, V14 Certified Nursing Assistant/CNA stated she was R2's Caregiver on 8/5/24. V14 stated that during R2's bed bath, she observed an open area on R2's coccyx. V14 stated, It was (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 2 Event ID: 145275 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 145275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 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)