Pekin Manor

In the surveyor’s words

From the most serious findings on record at Pekin Manor, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 27, 2025

  Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development, conduct a pressure ulcer risk assessment once a week for four weeks after admission and then quarterly thereafter, update pressure ulcer care plans with pressure relieving interventions, and failed to provide a treatment as ordered by the physician for three of three residents (R1, R2, and R3) reviewed for facility acquired pressure ulcers in the sample of four. […]

• Actual harm, isolatedF689Feb 10, 2025

  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. […]

• Actual harm, isolatedF689Dec 23, 2021

  Based on record review and interview, the facility failed to implement person centered fall prevention interventions and provide supervision to prevent a fall for one resident (R1) of three residents reviewed for falls. This failure resulted in R1 sustaining a fall . Findings Include: R1's Admission Nursing Notes, dated 12/3/21, document R1 was admitted to the facility from the hospital for Physical Therapy for strengthening, with plans to discharge to a lower level of care when possible. R1's Fall Risk Assessment, dated 12/6/21, documents R1 is High Risk for falling. R1's Fall Risk Assessment documents a diagnosis of Other symptoms and signs involving cognitive functions following other [CONDITION(S)] disease. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2022

  Based on observation, interview, and record review, the facility failed to maintain a clean kitchen including can openers, refrigerators, ovens and fans; failed to label and or discard food items as needed, and failed to keep scoops out of food bins. This has the potential to affect all 90 residents living in the facility. Findings: The Food Storage and Labeling Policy, dated 10/21, states Keep all food covered in a resealable bag or container or the original container if applicable. Discard any food item past it's use by date or expiration date. Do not store any utensil in a container of food. The label should include: Product Name; Date; Discard Date; Staff Initials. Items left in their original containers should say Opened with the date. […]

• No harm, potential for more than minimal, widespreadF880Sep 15, 2022

  Based on observation, interview, and record review, the facility failed to ensure all staff was wearing required Personal Protective Equipment (PPE) according to Centers for Disease Control (CDC)guidelines. This failure has the potential to affect all 90 residents in the building. Findings include: The facility's COVID-19 policy, dated 1/19/2022, documents the following: The Infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. […]