Inspection·December 6, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to perform pressure ulcer care and skin checks as ordered for one of three residents (R1) reviewed for pressure ulcer care in a sample of four. The facility's Pressure Injury Assessment and Treatment policy, dated 12/2024, documents to document in the resident electronic medical record when the treatment is completed. On 12/4/25, R1 stated that his wound care varies as to when it is completed. R1 stated that the wound care is done at least daily. R1's Treatment Administration Record, dated 11/12/25 through 12/4/25, documents to cleanse R1's left heel with soap and water. Apply Dakins (antiseptic) soaked gauze to the wound bed and cover with an abdominal pad, and cover with a gauze wrap and apply heel boots every day shift. This treatment is not signed out as being completed 11/12/25, 11/18/25, 1/19/25, 11/22/25 through 11/26/25, 12/1/25, and 12/2/25. This form also documents to perform daily skin checks. R1's daily skin checks were not signed out as being completed on 11/12/25, 11/19/25, 11/22/25 through 11/26/25, and 12/1/25 through 12/3/25. On 12/6/25 at 1:00pm, V4, Infection Preventionist/Treatment Nurse, stated that if the treatments are not signed out, then they were not completed as ordered. V4 stated the treatment is to be signed out when completing the care, and if the resident refuses, it should be documented in the progress notes. Residents Affected - Few 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 12/06/2025 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)