Inspection·June 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 4.) On 06/09/25 at 11:18 AM R7 and R68's window had no blinds, and the curtain was hanging halfway off the bracket and unable to be closed. R7 and R68's six-foot-long baseboard heater was lying on the floor, not attached to the wall. R7 and R68's bathroom floor had a thick brown stain surrounding the base boards and the toilet. On 06/11/25 at 11:33 AM V3 (LPN/Licensed Practical Nurse) verified R7 and R68's window had no blinds or curtains that were able to be closed. On 06/11/25 at 11:36 AM V18 (Housekeeper) stated, (R7 and R68's) bathroom floor has always been stained and (R7 and R68's) window has never had a working blind or curtains. I do not know how long the heater has been lying on the floor. Based on observation, interview, and record review the facility failed to ensure resident rooms were clean and free of urine odor, resident room windows had privacy blinds or curtains in good repair, resident heating units were properly attached to the wall, and failed to ensure all resident rooms had adequate cooling for five of 18 residents (R4, R7, R9, R38 and R68) reviewed for homelike environment in the sample list of 40. Findings include: The facility's Resident Rights policy dated 12/2024 documents it is the responsibility of the staff in the facility to provide services to the residents, and advocate for Resident Rights. 1.) 06/10/25 10:36 AM 06/09/25 11:17 AM R4 had two cardboard boxes taped to the window covering the windows with silver tape. On 6/10/25 at 12:10 PM, V20 (Certified Nursing Assistant) stated there are cardboard boxes that cover windows because the windows let in hot/cold air. 06/09/25 11:00 AM, V5 (Maintenance Director) stated the blinds do not block out the sun, so residents will often ask to have boxes over the windows. V5 further stated the facility plans to fix the issues in the facility, but they have not been given the funding to do so yet. 2.) 06/09/25 02:07 PM R9's room had a very strong smell of urine. On top of R9's bedside table was a full urinal of amber colored urine. R9's bed had no fitted sheet and R9 was laying on top of the mattress. R9's floor was sticky with dirt and debris. (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 06/11/2025 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)