Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation and record review, the facility failed to ensure the floor was free and clear of trip
hazards for one of three residents (R1) reviewed for falls with injury in a sample of four. On 01/05/25, R1 fell
at the facility after a cord on the floor of the walkway entering her room became trapped in the wheel of her
walker. R1 sustained a laceration to her forehead requiring placement of nine sutures, a skin tear and
bruising to her right third finger, and fractures to C1 (first cervical vertebrae) and C2 (second cervical
vertebrae), requiring R1 to wear a hard cervical collar at all times.
Findings include:
R1's Fall Investigation (dated 01/05/25) documents the following: On 01/05/25, at approximately 03:10 PM,
RN (Registered Nurse) was notified by CNA (Certified Nursing Assistant) resident (R1) had a witnessed
fall. Resident was walking with her walker and assist of one CNA with gait belt in place to the bathroom
when resident's walker caught on the bed remote causing resident to lose her balance and fall to her right
side. Nurse immediately went to assess the resident upon notification of fall. The resident was observed
lying on the floor near the end of her bed with a CNA holding a washcloth to resident's forehead, shoes on
with laces tied, walker near feet lying on its side, gait belt in place. RN completed assessment and noted
laceration to center of forehead, skin tear to middle finger of right hand with bruising and vitals WNL (within
normal limits). Nurse noted resident pain to be a 6 out of 10. CNA continued to apply pressure to forehead
and keep resident's head secured until (local ambulance transport service) arrived. Resident is current with
hospice care. Resident was transported to (local emergency department) for further evaluation/possible
treatment. POA (Power of Attorney), MD (Physician), Hospice, and (V2, Director of Nursing) were notified.
Staff interviews conducted post event were completed. CNA stated at approximately 03:10 PM, she was
walking resident to the bathroom with resident's walker and a gait belt in place when resident's walker
caught on the bed remote causing the resident to lose her balance and fall to her right side. Resident was
evaluated in (local emergency department). Resident returned to (facility) 01/05/25 for continued long term
care. Diagnosis: Cervical Fracture of C1 & C2 (with Cervical Collar in place) and laceration to forehead with
nine stitches. Resident POA (Power of Attorney) chose no surgical intervention at this time and to remain of
hospice care keeping resident comfortable. Hospice adjusted pain medication to help ensure resident
comfort. Family to provide more frequent monitoring. New interventions put into place, staff educated and
care plan updated. POA and MD (Physician) notified and are in agreement with plan of care.
R1's 01/05/25 Fall Investigation also documents the following: Evaluation Notes: (R1) is alert with confusion
at baseline (Brief Interview of Mental Status score of 3, indicating severe cognitive impairment), (R1) had a
witnessed fall in her bedroom while ambulating with CNA (V6, Certified Nursing
(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
02/10/2025
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 - Actual harm
Residents Affected - Few
Assistant), resident's walker got wrapped in the bed remote cord, this is believed to be the root cause of the
incident. (R1) obtained C1 and C2 fracture, laceration and bruising as result from this incident. Care Plan
reviewed, new intervention: bed remote control fixed to bed.
On 02/05/25 at 01:25 PM, V5 (Certified Nursing Assistant) verified her written statement included in R1's
01/05/25 fall investigation and stated the following: I was right across the hall when (R1) fell. (V6, Certified
Nursing Assistant) was walking (R1) into her room, and (V6) called out for help after the fall. The right front
wheel of (R1's) walker ran over the loose cord that was on the ground in the walkway near the footboard of
(R4's, R1's roommate) bed. The cord was hanging from (R4's) bed and it caused (R1) to fall after it got
stuck in her walker's wheel. The cord connects to the bed remote, which (R4) cannot utilize due to her
Dementia. The cord was still stuck around the right front wheel of (R1's) walker when I entered the room.
(R4) had just moved back into that room a day or two before (R1's) fall. The bed remote cord must have
become unsecured when (R4's) bed was moved. I went and got (V12, Registered Nurse), who responded
to R1's room right away.
On 02/05/25 at 03:50 PM, V6 (Certified Nursing Assistant) stated she was the staff member assisting R1
when she fell. V6 stated, The cord from the bed remote of (R4's) bed had came loose. It was dangling from
the underneath of (R4's) bed and was sitting on the floor. I was walking with (R1) to the bathroom. She uses
a walker when she walks, and I had a gait belt on her. She must have ran over the remote cord hanging
from (R4's) bed while we were walking into the room. While we were walking, I felt (R1) suddenly jolt
backwards. I'm guessing this is when the cord that was tangled in the wheel of her walker became taut, and
this caused her to lose her balance and fall. I tried to stop her, but she just went down so quick. After she
had fallen, you could see the cord from (R4's) bed was tangled in the right front wheel of (R1's) walker. She
had a big cut in the middle of her forehead, and a skin tear on her right middle finger. (V5, Certified Nursing
Assistant) was right across the hall in another resident's room, and I called her to come in the room for
help. She came into R1's room, I explained what had just happened, and she immediately went and got
(V12, Registered Nurse), who came in right away.
On 02/05/25 at 02:30 PM, V9 (Certified Nursing Assistant) stated she was working when R1 fell on [DATE].
V9 stated, I last saw (R1) when she was in the day room. (V6, Certified Nursing Assistant) was walking with
her when she fell. The cord from a bed remote got stuck in the wheel of her walker. I saw the cord stuck in
the wheel when I entered the room after (R1) fell.
On 02/10/25 at 08:30 AM, V12 (Registered Nurse) stated she was the nurse that responded after R1's
01/05/25 fall. V12 verified her written statement form R1's fall investigation, which documents the following:
This nurse was called to (R1's) room by (V5, Certified Nursing Assistant) due to resident being on the floor.
Resident observed on floor with another CNA (V6, Certified Nursing Assistant) holding wash cloth to
resident's forehead, shoes on with laces tied, walker near feet lying on its side, gait belt in place. Upon
inspection, resident observed to have a laceration to center of forehead, skin tear to middle finger of right
hand with bruising and knot present. Fall witnessed by (V6, Certified Nursing Assistant). Pressure applied
to forehead and sent to ER (Emergency Room) for further evaluation. Hospice, MD (Physician), POA
(Power of Attorney) and (V2, Director of Nursing) notified. V12 stated due to R1's extensive confusion, she
estimated R1's pain to be a 6 out of 10 based on the Wong-Baker Faces Pain Scale (visual analog pain
scale used to assess pain in children and adults).
On 02/05/25 at 01:45 PM, R1 was reclined in a recliner with a blanket covering her lap near the nurse's
station. R1's eyes were closed, and a hard cervical collar was in place around R1's neck. R1
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 2 of 3
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
02/10/2025
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 - Actual harm
Residents Affected - Few
appeared confused, did not open her eyes or respond to verbal stimuli, and was moaning incomprehensible
phrases. A moon-shaped scar with well-approximated edges was present in the middle of R1's forehead. A
small scabbed area with faint bruising was present on R1's right third digit.
R1's (local hospital) emergency department medical record (dated 01/05/25) documents the following: HPI
(History of present illness): Patient is a [AGE] year-old female who presents to the emergency department
today for evaluation of injuries sustained from a ground level fall. She has a history of advanced dementia
and resides at a nursing facility. She is currently enrolled in hospice but due to the size of lacerations
involved she was sent here for evaluation and repair of the lacerations. It is reported that she fell forward.
Sustained a large laceration to her forehead and a laceration to her right middle finger. (R1) Has also been
complaining of some neck pain since the fall occurred. She is not on any form of blood thinners. She did not
lose consciousness. She has not had any vomiting since injury occurred. This same medical record also
documents, Skin: Positive for wound (large forehead laceration); Comments: 10 centimeter laceration to
forehead with visualized portion of skull; Neck: Diffuse posterior neck tenderness; Musculoskeletal: 1.5
centimeter laceration to dorsal aspect of right middle finger.
R1's same (local hospital) medical record documents the following: CT (computed tomography) Cervical
Spine without Contrast: Cervical: There is an acute, obliquely oriented, complete type II fracture of the base
of the dens (second cervical vertebrae). There is no displacement at the fracture site at this time. An acute,
nondisplaced fracture of the right-sided posterior arch of C1 (first cervical vertebrae) is also present.
R1's (local hospital) emergency department medical record also documents the following: Medical Decision
Making: CT (computed tomography) of the head showed no acute fractures or bleeds. Unfortunately, CT of
the cervical spine did show a nondisplaced type II dens fracture with a non-displaced posterior arch
fracture of C1 on the right side. I did discuss patient's case with (V15, local Neurosurgeon) who was on
on-call for Neurosurgery. He notes that this would usually require surgical repair. However, patient is a
hospice patient with advanced dementia. Family is very reluctant to have her undergo surgery. (V15) notes
if this is the case the only other alternative would be to place patient in (hard cervical collar). Patient's
power of attorney had extensive discussion with other family members. It was decided by family and power
of attorney that they would forego extensive trauma workup or surgical intervention. They would like patient
to be kept as comfortable as possible. They do understand that if patient moves her neck in certain way
could lead to neurological defects or death. They would like to respect her wishes and allow her to be
discharged back to the nursing facility on hospice. We will provide her with a small amount of Lortab (pain
medication) elixir. She tolerated suture procedure of her forehead very well. Dissolvable sutures were
placed so she would not have to undergo suture removal. Well, the laceration on her finger could benefit
from some sutures. The edges are well-approximated and attempting to repair it has caused her distress.
Family is okay with just bandaging the finger for now and letting it heal.
On 02/05/25 at 03:20 PM, V1 (Administrator) verified R1 fell as a result of her wheeled walker contacting a
cord that was hanging from the foot of R4's bed. V1 verified that R1 has to ambulate past R4's bed to enter
her bathroom. V1 verified that R1 returned to the facility after her evaluation in the local emergency
department with a C1 and C2 fracture sustained during her fall on 01/05/25, requiring R1 to wear a hard
cervical collar. V1 also verified R1 had 9 sutures placed to a large laceration in her forehead, and had a
dressing in place on the skin tear sustained to her right third digit after her 01/05/25 fall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145597
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the February 10, 2025 survey of PEKIN MANOR?
This was a inspection survey of PEKIN MANOR on February 10, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PEKIN MANOR on February 10, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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.