Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to cover a urinary catheter bag with a privacy
bag for one of 24 residents (R18) reviewed for dignity in the sample of 33
Findings include:
The Resident Rights Booklet, dated 11/18, documents, Your facility must treat you with dignity and respect
and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean,
comfortable, and homelike.
R18's current computerized medical record documents R18 was admitted to the facility on [DATE], with
diagnoses which included Neuromuscular Dysfunction of Bladder, Overactive Bladder, Type 2 Diabetes
Mellitus with Diabetic Neuropathy, and Essential (Primary) Hypertension.
R18's MDS (Minimum Data Set) Assessment, dated 8/29/24, documents a BIMS (Brief Interview for Mental
Status) Score of 14/15, indicating cognition intact and has an indwelling catheter.
R18's Care Plan, dated 8/18/21, documents R18 has a catheter related to neuromuscular dysfunction of
bladder.
R18's Physicians Order, dated 12/19/23, documents R18 has a (indwelling) catheter.
On 9/23/24 at 12:20 PM, R18 was sitting in the dining room. R18's urinary drainage bag was not covered
with a privacy bag. The urinary drainage bag was hooked under R18's chair, and the bag with urine was
visible. R18 was asked if she would like the catheter bag to be covered. R18 stated she thought it was
covered and if not, she would like it covered.
On 9/23/24 at 12:25 PM, V4/Registered Nurse verified R18's catheter bag was not covered with a privacy
bag, but should be.
On 9/25/24 at 10:12 AM, V2/Director of Nursing stated catheter bags are to be covered with a privacy bag.
V2 also stated, There is no policy for using a dignity bag to cover the catheter bag, but that is standard
practice.
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 6
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
09/26/2024
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)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to notify the facility Ombudsman of Facility
Discharges/Transfers, monthly, for two residents (R26 and R67) of 7 reviewed for discharges in the sample
of 33.
Findings include:
1. R26's current Medical Record, documents R26 was admitted to the facility on [DATE], with diagnoses
which included Chronic Obstructive Pulmonary Disease, Anxiety, Vascular Dementia, Peripheral Vascular
Disease, Fibromyalgia, Essential (Primary) Hypertension, and Severe Sepsis with Septic Shock
R26's Nursing Note, dated 6/3/24 at 10:56 AM, documents R26 was taken to the hospital for evaluation.
R26's Nursing Note, dated 6/3/24 at 11:13 AM, documents R26 was admitted to the hospital with a
diagnosis of UTI/Urinary Tract Infection.
R26's Social Service Note, dated 6/11/24 at 12:15 PM, documents R26 was back in the facility.
R26's Nursing Note, dated 6/18/24 at 6:23 AM, documents emergency services were called to take R26 to
the Emergency Room.
R26's Nursing Note, dated 6/18/24 at 9:51 AM, documents R26 is being admitted to the hospital.
R26's Nursing Note, dated 6/26/24 at 5:24 PM, documents R26 returned from the hospital.
R26's Bed hold Notice, dated 6/4/24, documents R26 went to the hospital on 6/3/24 for a diagnosis of UTI/
Urinary Tract Infection. R26's Bed Hold Notice, dated 6/19/24 documents R26 went to the hospital for
sepsis.
The Admit/Discharge Report, dated 6/1/24 - 6/30/24, does not document R26 was discharged to the
hospital on 6/3/24 and 6/18/24.
On 9/25/24 at 10:37 AM, V5/Social Services stated R26 was not on the June 2024 list of admit/discharge
that was provided to the Ombudsman. V5 also stated, The information was put in the system. I don't know
why it didn't show up on the report.
2. R67's current Medical Record documents R67 was admitted to the facility on [DATE], with diagnoses
which included Chronic Kidney Disease Stage 3, Sepsis, Anxiety, Essential (Primary) Hypertension, and
Chronic Systolic (Congestive) Heart Failure.
R67's Nursing Note, dated 1/9/24 at 4:46 PM, documents R67 was not responding to questions or stimuli.
R67 was sent to the hospital for evaluation and treatment. R67 left the facility at 4:40 PM.
R67's Nursing Note, dated 1/9/24 at 6:07 PM, documents R67 was admitted to the hospital with a diagnosis
of UTI/Urinary Tract Infection.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 2 of 6
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
09/26/2024
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)
F 0623
R67's Nursing Note, dated 1/13/24 at 1:46 PM, documents R67 returned to the facility.
Level of Harm - Minimal harm
or potential for actual harm
R67's Bed Hold, dated 1/10/24, documents that R67 went to the hospital on 1/9/24 with a diagnosis of
UTI/Urinary Tract Infection.
Residents Affected - Few
The Admission/Discharge Log, dated 6/1/24 to 6/30/24, does not document R67 was discharged to the
hospital on 1/9/24.
On 9/25/24 at 10:42 AM, V5/Social Services stated R67 was not on the January 2024 list of
admit/discharge that was provided to the Ombudsman. V5 also stated, The information was put in the
system. I don't know why it didn't show up on the report.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 3 of 6
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
09/26/2024
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to develop a Person Centered Care Plan for one resident
(R67) out of 24 reviewed for Care Plans in a sample of 33.
Findings Include:
The Care Plan Policy, dated 6/1/22, documents, It is the policy of this facility to develop and implement a
Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as
appropriate for each resident, consistent with resident rights, that includes measurable objectives and
timeframe's to meter resident's medical, nursing, and mental and psychosocial needs that are identified in
the resident's comprehensive assessment. 6. The comprehensive care plan will be developed within 7
(seven) days after the completion of the comprehensive MDS (Minimum Data Set) assessment as outlined
in the RAI (Resident Assessment Instrument) manual guidelines. Address other factors identified by the
interdisciplinary team, or in accordance with the resident's preference, will also be addressed in the plan of
care. 9. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each
comprehensive and quarterly MDS assessment.
R67's current Medical Record documents R67 was admitted to the facility on [DATE], with diagnoses which
included Chronic Kidney Disease Stage 3, Sepsis, Anxiety, Essential (Primary) Hypertension, and Chronic
Systolic (Congestive) Heart Failure.
R67's MDS (Minimum Data Set) Assessment, dated 1/20/24, documents R67 takes an anticoagulant.
R67's Physicians Order for Eliquis 5 mg/Milligrams documents a start date of 1/13/24, Take Eliquis 5 mg
twice a day.
Care Plan, dated 9/24/24 at 3:59 PM, documents, (R67) uses an anticoagulant medication related to CHF
(Congestive Heart Failure).
On 9/26/24 at 9:32 AM, V10/MDS/Care Planner, stated R67 did not have a Care Plan for an anticoagulant
until 9/24/24, although there should have been.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 4 of 6
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
09/26/2024
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to change an oxygen tubing/humidifier bottle for
one resident (R2) of two residents reviewed for oxygen therapy in the sample of 33.
Residents Affected - Few
Findings Include:
The Oxygen Therapy policy, dated 3/16/17, documents, To provide a source of oxygen to persons
experiencing an insufficient supply of same. Procedure: 7. Oxygen set-up (cannula/mask, tubing) must be
exchanged every 7 (seven) days.
R2's current Medical Record documents R2 was admitted to the facility on [DATE], with diagnoses which
included Acute Respiratory Failure with Hypoxia (Primary), Chronic Obstructive Pulmonary Disease, Acute
and Chronic Respiratory Failure with Hypercapnia, and Shortness of Breath.
R2's Care Plan documents R2 has COPD/Chronic Obstructive Pulmonary Disease, Chronic Respiratory
Insufficiency, Obstructive Sleep Apnea, Restrictive Lung Disease, Recent Respiratory Acidosis, Recent
Acute Hypercapnia, and Respiratory Failure. R2's oxygen setting is to be at three liters.
R2's Physician Order, dated 3/30/24, documents oxygen at three liters continues every shift.
R14's Physician Order, dated 3/12/24, documents oxygen at 2 (two) liters per minute by nasal cannula
every shift.
On 9/23/24 11:25 AM, R2 was sitting in her room wearing oxygen. It was connected to the humidifier bottle.
The humidifier bottle was dated 8/18/24.
On 9/23/24 at 11:26 AM, V4/Registered Nurse verified the date on the humidifier bottle was 8/18/24. V4
also stated the tubing and humidifier bottle is to be changed weekly on the night shift.
On 9/25/24 at 10:12 AM, V2/Director of Nursing stated oxygen tubing and humidifier bottles are supposed
to be changed weekly. The staff are to date the tubing and humidifier bottle when they are changed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 5 of 6
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
09/26/2024
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on observation, interview, and record review, the facility failed to document a diagnosis and monitor
for specific adverse behaviors to warrant the use of an antipsychotic medications for one of five residents
(R249) reviewed for unnecessary medications in a sample of 33.
Findings include:
The facility's Psychopharmacological Drug Usage Procedure, revised 10/18/17, documents the
documentation of behaviors and conditions requiring the use of these medications must be done on a
routine basis, as well as medications response and adverse consequences.
R249's current Medication Administration Record documents to take Quetiapine (antipsychotic) 25mg daily
for Alzheimer's disease, unspecified.
On 9/23/24 at 10:30am, R249 was being assisted to his wheelchair, cooperative with care.
On 9/24/24 at 1:30pm, R249 was sleeping in his wheelchair.
On 9/25/24 at 10:30am, R249 was sleeping in his wheelchair. R249 was encouraged to lay in bed but
refused.
On 9/25/24 at 11:30am, V13, Certified Nursing Assistant, stated R249 does not show any signs of adverse
behaviors. V13 verified R249 is cooperative with care.
On 9/25/24 at 1:30pm, R249 was sleeping in his wheelchair in his room.
On 9/25/24 at 11:45am, V6, Assistant Director of Nursing, verified R249 does not have any adverse
behaviors or diagnosis for the use of an antipsychotic medication. V6 stated R249 shows signs of increase
confusion in the evenings, but is easily redirected.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 6 of 6
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the September 26, 2024 survey of PEKIN MANOR?
This was a inspection survey of PEKIN MANOR on September 26, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PEKIN MANOR on September 26, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.