Inspection·December 12, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident safety during van transportation for one (R1) of three residents reviewed for accidents in a sample of five. This failure resulted in R1 sustaining a fall and suffering from pain and fractured ribs. Findings include: The facility's Fleet Safety Program, undated, documents, Safety Policy: (Named facility) has implemented a fleet management program to establish minimum safety requirements for the operation of vehicles used for company business. We are committed to providing and maintaining a safe working environment for our employees and protecting our residents and citizens of the community from injury and property loss. Your commitment to these policies and procedures are vital to building a safe driving culture within (named facility) and ensuring your own safety, the safety of others and the success of the business. This document continues to state Employee/Driver: Comply with the requirements of this program .Follow all safe driving rules, traffic regulations, and ensure driver(s) and all passengers are wearing appropriate securement device (e.g., seat belt and shoulder harness, wheelchair securement straps.) The consent form included in this Fleet Safety Program includes As a driver of a company vehicle or a private vehicle on company business I understand that it is my responsibility to operate the vehicle in a safe manner and follow to drive defensively to prevent injuries and property damage. R1's Quality Care Reporting Form, dated 11/12/24, documents R1 had a fall in the parking lot resulting in a small discoloration and pain to R1's chin. R1 was sent to the hospital for evaluation and treatment. Summary of event and any actions taken: Transport staff to be educated on safety and proper transportation safety. R1's hospital Emergency Provider Notes, dated 11/15/24, documents, HPI (History of Present Illness): Patient reportedly fell on [DATE]. She was reportedly in a handicap van and was being unloaded, however the lift was not up, and her wheelchair was rolled/dropped out of the van. She fell to the ground and struck her face/head and landed on her left side. She was evaluated at (named facility) who did a CT (Computed Tomography) of her head and neck but did not do imaging of her back/ribs. R1's hospital CT Chest without Contrast, dated 11/15/24, documents, Impression: 1. T8-T9 left rib fractures with associated small hemothorax. On 12/11/24, at 11:43am, R1 sat in a wheelchair in a lounge area. R1 stated the following: I was in the back of the van, and she (V7 Transportation driver) pushed me up (to the rear of the van). I (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 12/12/2024 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)