Inspection·March 6, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent misappropriation of property for 1 resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. Residents Affected - Few The Findings include: The Abuse policy, dated 11/28/19, documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown sources, exploitation and use of any physical or chemical restraint not required to treat residents' symptoms. To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. The Final Investigation Report sent to the (State Agency), dated 2/13/24, documents a Drug Diversion Investigation. On 2/8/24, V2 (Regional Nurse Coordinator) notified V1 (Administrator) of a possible drug diversion for a bottle labeled Morphine Sulfate. During a routine medication cart audit by V4 (Pharmacy Nurse Consultant), V4 noted a bottle labeled morphine sulfate for R1. The bottle was stored in a zip lock bag along with the dosing syringe. The content of the bottle was gray in color. The morphine that is provided by the facility pharmacy is blue in color. V4 removed the bottle of morphine and the sign out sheet and took it to V5 (Previous Director of Nursing) due to her concerns. V4 left the bottle labeled Morphine for R1 containing the gray liquid, sign out sheet, and dosing syringe in V5's office. V5 and V3 (Assistant Director of Nursing) immediately initiated an investigation. After completion of interviews with all nursing staff, the time frame for this occurrence has been determined to be after 1/22/24. R1's Physician Order, dated 12/6/22, documents, Morphine Concentrate - Schedule II solution; 100 mg (Milligram)/5 ml (Milliliter) (20 mg/ml); Amount to Administer: 0.25 ml; oral. R1's Controlled Substance Record documents 30 ml of Morphine was delivered on 12/6/23. There was 27.5 ml remaining out of 30 ml. At the top of the sheet written in marker is Dark color - reported. R1's Medication Administration Record documents the last time R1 received Morphine was on 1/21/24 at 1:54 PM given by V16. On 3/5/24 at 10:56 AM, V3 had two bottles of Morphine. The bottles were white plastic with a clear area on the side where the medication could be seen and measured. The contents of R1's bottle was gray in color. The bottle had 27.5 ml of liquid in it out of the original 30 ml's. The unopened bottle of morphine was blue in color. R1's Morphine bottle had an expiration date of 7/25. (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: 145597 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 03/06/2024 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)