Inspection·July 8, 2023

F 0657 On 7/8/23 at 12:27 PM, V1, Administrator, verified R1's new onset of right upper extremity pain was not added to the care plan. 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: 145597 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to assess, investigat,e and notify the physician of a possible resident injury for one resident (R1) out of three residents reviewed for injury in a sample of three Residents Affected - Few Findings include: The facility's Accident and Incident Report policy, dated 4/2/19, documents, Objective: 1. TO document all accidents/incidents occurring to resident's, visitors and employees. Resident: A. Provide necessary emergency care. B. Notify Charge Nurse, who then must notify Physician and family. C. If there has been no apparent injury, follow-up must continue for 24 hours. D. If there is apparent injury, follow-up must continue for at least 72 hours. E. Documentation must be on Resident Accident and Incident Report as well as in the Nurse's Notes. R1's minimum data set (MDS) documents a Brief Interview of Mental Status (BIMS) of 14. A BIMS of 12-15 indicates an individual in cognitively intact. R1's physical therapy notes, dated 6/17/23, documents, (R1) stating her right arm hurts, states night male CNA (Certified Nursing Assistant) hurt it when transferring her out of her recliner to go to the bathroom last PM he didn't mean to, but pulled on it to help get me up. Took patient to floor nurse to give report of events. After, patient was given medication by nurse and agrees to do therapy. R1's physician visit summary, dated 6/19/23, documents, Seen today for follow-up-up service since recent admission to skilled nursing facility .(R1) reports pain to the right upper extremity as an 8-9, states she thinks her arm was strained during mobility or transfer recently. R1's progress noted does not document a resident reported incident of injury. R1's medical record does not include an investigation into R1's reported incident of injury. On 7/6/23 at 9:03 AM, R1 stated, I'm not sure what day it was, but a staff member was trying to help me get out the recliner and I felt a pop in my shoulder, and it started hurting. I told the nurse when it happened.' On 7/6/23 at 10:56 AM, V4, Advanced Practice Nurse (APN) stated, I saw (R1) on 6/19. At that time, (R1) was complaining of pain to her right upper extremity (RUE). I ordered an X-ray to rule out any injuries. According to my notes, the facility never contacted me. I saw (R1) on 6/19 as part of a routine follow-up. I followed up with (R1) on 6/22 to let her know her right shoulder pain was due to significant arthritis in that joint. She was still complaining of pain, so I gave a new order for some pain medications. I believe the pain was due to her therapy sessions. It's common to see an increase in pain in arthritic joints during therapy. That's why I wanted her to rest it a few days before trying any pain medications. On 7/8/23 at 9:00 AM, V5, Licensed Practical Nurse (LPN), stated, I was working Monday (6/19) when I heard (V4, APN) tell the bridge nurse to put in an X-ray order for (R1)'s right upper extremity. I asked why they were putting in an order for it when she didn't say anything to me about any new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145597 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 145597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pekin Manor 1520 El Camino Drive 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pain. I was told that she hurt her arm over the weekend, possibly while therapy was working with her to get her out of her chair. From what I understand, therapy questioned (R1) about it, and (R1) said that it wasn't therapy, it was a male CNA that was trying to get her out of her chair and accidentally hurt her arm. On 7/8/23 at 12:24 PM, V2, Director of Nursing (DON), stated, In a situation like (R1)'s, the nurse should have done an assessment when it was reported to her on 6/17, documented the incident, started an incident report and notify the administration and physician. Unfortunately, it wasn't done. Event ID: Facility ID: 145597 If continuation sheet Page 4 of 4