Inspection·April 4, 2025

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 ensure residents consumed their medications for five residents (R1, R2, R3, R5 and R7) and the facility failed to have a physician's order for medication administered for one resident (R7) of 8 residents reviewed for medication administration. Residents Affected - Some Findings Include: The Facility's Medication Administration policy dated 12/16/24 documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a until dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The Facility's Medication Administration policy documents, Observe the resident consume the medication to insure resident swallows medication. Never leave prepared medications unattended. No medications should be left at bedside unless specifically ordered by the physician and then only in limited amounts as described by the physician. 1. On 4/2/25 at 9:00 AM R2 was sitting up in his bed with the head of the bed up. R2 had a medicine cup full of pills on his bedside with his name written in black marker across the side. R2 stated those were his morning medicines that (V6/LPN) brought him to take. R2's April Medication Administration Record documents, R2's morning medicine as: Bisoprolol Fumarate 5 mg (milligrams), Finasteride 5 mg, Furosemide 20 mg, Losartan Potassium 50 mg, Phentermine HCL 37.5 mg, Tamsulosin .4 mg Bactrim DS 800-160mg, Eliquis 5 mg, and hydralazine 50 mg. 2. On 4/2/25 at 9:05 AM R1 was sitting in her bed with the head of the bed up. R1 had a medicine cup full of pills on her bedside table that were spilled and R1 was rolling the pills towards her one by one and taking them. R1 stated she spilled her medicine, so she was rolling it towards herself and then taking it. R1 was not sure what kinds of medicines were in the cup. R1's April Medication Administration Record documents R1's morning medications as: Jardiance 25 mg (milligrams), Multivitamin 1 tablet, Oyster Calcium 1 tablet, Docusate Sodium 100 mg, Eliquis 5 mg, Enalapril Maleate 10 mg, Metoprolol Tartrate 50 mg and Gabapentin 600 mg. 3. On 4/2/25 at 9:07 AM R1's roommate (R5) was taking medicine out of a medicine cup with his name written on the side. R5 confirmed that those were all his scheduled morning medicines. (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 3 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 04/04/2025 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)