Health inspection·November 8, 2024

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 Observation, Interview and Record review, the facility failed to complete physician ordered wound treatments daily for one of three residents (R1) reviewed for Wound Care in the sample of three. Residents Affected - Few Finding Include: The facility's Health Care Decubitus Care/Pressure Areas policy, dated 1/2018, documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Complete all areas of the Treatment Administration Record or Wound Documentation Record. Initiate physician order on the treatment sheet. Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. On 11/4/2024, at 11:28 AM, R1 had a surgical wound to left stump that was red where sutures were, with minimal swelling. Wound was 3cm in length, 2cm in width, and was 1.2cm deep. Wound was bleeding and had blood dripping on the floor. R1 stated that the wound was sensitive to touch, and hurts when it is touched, or during wound dressing changes. R1 stated that wound dressing changes were not done daily. R1's October 2024 Treatment Administration Record (TAR), documents a Physician ordered wound treatment of L (left) stump-apply NS (normal saline) soaked gauze to open area, wrap with (elastic bandage), secure with tape, and apply (compression sock) daily. This order has a start date of October 7th, 2024. This same TAR documents on October 8, 16, 17, 19, 22, 23 ,24, 25, and 31, R1's treatments were not completed. R1's November 2024 Treatment Administration Record (TAR), documents a Physician ordered wound treatment of L (left) stump-apply NS (normal saline) soaked gauze to open area, wrap with (elastic bandage), secure with tape, and apply (compression sock) daily. This same TAR documents on November 1, R1's treatment was not completed. On 11/6/2024 at 2:00 PM, V2 (Director of Nursing) stated V2 was not reading the order for R1's wound change to be done daily and read the order as PRN (as needed). V2 stated, Yes, nursing staff should have been doing the wound dressing changes daily as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145275 If continuation sheet Page 2 of 4 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 11/08/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow Enhanced barrier precautions while performing wound care and follow hand hygiene for one of three residents (R1) reviewed for Wound Care, and Infection Control in a sample of three. Residents Affected - Few Findings include: The Facility's Enhanced Barrier Precautions Policy, dated 7/13/23, documents, Enhance Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change. Enhance Barrier Precautions require use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a resident's room, when high-contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed when performing transfers in the shower/assisting with shower and when assisting a resident with toileting in common restrooms. High contact care activities include: Wound care (pressure ulcers, diabetic ulcers, unhealed surgical wounds, chronic venous stasis wounds). The Facility's Hand Hygiene Policy, dated 8/14/23, documents, All staff will comply with current CDC hand hygiene guidelines to reduce the incidence of healthcare associated infections. Indications for Hand Washing-When hands are visibly soiled or contaminated with blood or other body fluids, before and after eating and using the restroom. Handwashing can also be used routinely in the following clinical situations: 1. After contact with body fluids, excretions, mucous membranes, non-intact skin and wound dressings. 2. Before and after direct resident care. 4. When moving from contaminated body site to clean body site during resident care. 5. After contact with intact skin. 6. After removing gloves. Indications for Alcohol Based Hand Rub (ABHR)-When hands are not visibly soiled, ABHR may be used for routinely decontaminating hands in the following clinical situations: 1. Before and after having direct contact with residents. 3. After contact with a resident's intact skin. 4. After contact with inanimate objects (including medical equipment). 5. After removing gloves. On 11/4/2024 at 10:28 AM, V3 (LPN) entered R1's Enhanced Barrier Precautions room without a gown, V3 washed hands, and applied gloves. V3 removed compression wrap, removed tape, removed gauze and disposed in trash can. Surgical site was red around suture area, with minimal swelling. V3 removed gloves and went to get a cotton swab stick, along with measuring tape. V3 did not sanitize hands or wash them before donning new gloves as she reentered the room. On the distal portion of the surgical site there was an opening wound where the sutures were closed making a wound 3cm in length, 2cm in width, 1.2cm deep. Wound was bleeding and had blood dripping on the floor. V3 cleansed the wound with wound cleaner, soaked gauze with wound cleaner, placed gauze around wound. V3 then wrapped gauze around lower leg and below the knee and secured gauze with tape. V3 removed gloves and labeled tape. On 11/4/2024 at 10:45 AM, V3 (LPN) stated that she forgot R1 was in Enhanced Barrier Precautions and explained the reason R1 was in Enhanced Barrier Precautions was maybe due to her oxygen, I need to go look into that. V3 stated that she realized she did not wear a gown and that she did not practice hand hygiene when she returned from grabbing the cotton swab on a stick and measuring tape. On 11/6/2024 at 2:00 PM, V2 (Director of Nursing) stated in Enhanced Barrier Precaution rooms, that staff should be wearing a gown and gloves when having direct contact cares or when changing linens. V2 stated staff should be practicing hand hygiene. V2 stated staff should use hand sanitizer before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145275 If continuation sheet Page 3 of 4 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 11/08/2024 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)

F 0880 entering a room, and before exiting a room unless the resident is in a contact precaution room or if there is visible soiling then the staff member should be washing their hands. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145275 If continuation sheet Page 4 of 4