Timbercreek Rehab and Health Care Center

At least twice every year, the Centers for Medicare and Medicaid Services (CMS) and state nursing home regulators conduct unscheduled surveys on every nursing home in Illinois. These intensive inspections are used to identify problems, deficiencies, and serious regulatory violations. Also, the surveyors conduct unannounced investigations to respond to formal complaints filed by residents, visitors and employees at the facility.

When serious deficiencies are identified, the nursing home may receive a fine and guidance on how to correct the problems promptly to ensure the residents’ health and well-being are protected and maintained. In some cases, the violations are so egregious or harmful to the resident that the nursing home is placed on a Federal watchlist and designated as a Special Focus Facility (SFF).

More than a year ago, Timbercreek Rehabilitation and Health Care Center was designated by the Centers for Medicare and Medicaid Services as a Special Focus Facility and was added to the national watch list. The nursing home is now required to improve their policies, procedures, and protocols to ensure the nursing staff and administration are following the rules and regulations a court of the State and Federal laws.

Likely, the Peterson HealthCare-affiliated facility will remain on the watch list for years to come as investigators and surveyors review the changes made at the nursing home to ensure the corrections or permanent.

Timber Creek Rehab and Health Care Center

This 202 certified-bed Medicare/Medicaid-participating facility provides cares and services to the residents of Pekin and Tazewell County, Illinois. The Nursing Home is located at:

2220 State Street
Pekin, IL 61554
(309) 347-1110

In addition to providing around-the-clock nursing care, the facility also offers Alzheimer’s care, memory care, depression management, substance dependency care, coping skills, aggression management, socialized activity programming, adult life skills training, symptom management, and their proprietary Pathways Rehabilitation services.


Investigators working for Medicare and Medicaid will issue monetary fines that serve as a penalty against the nursing home that are used as an incentive to facilitate much-needed changes. On February 23, 2015, CMS issued a $6,561 fine against Timbercreek Rehabilitation and Health Care Center.

Additionally, Medicare denied the facility a request for payments on services rendered three times in three years, including on February 23, 2015, August 5, 2016, and December 2, 2016. This payment denial was based on substandard care and dangerous hazards at the facility by the nursing staff.

Current Nursing Home Resident Safety Concerns

The state of Illinois and federal regulators routinely update the national Medicare.gov website with information collected by surveyors and investigators concerning every nursing home in the US. Families use this data to understand better which nursing facilities in the local community provide the highest level of care to the residents.

Based on the website star-rating summary system, Timbercreek Rehab and Health Care Center currently maintains a much below average one out of five stars overall compared to all other facilities nationwide. This ranking includes one out of five stars for health inspections, three out of five stars for staffing, and one out of five stars for quality measures. Some concerns over serious violations and deficiencies are listed below.

  • Failure to Provide Care That Prevents the Development of a Bedsore or Allows an Existing Bedsore to Heal

  • In a summary statement of deficiencies dated July 20, 2017, the state investigator noted that the facility had failed to “provide treatment ordered for multiple open wounds for [a resident at the facility].” A review of the resident’s July 2017 Wound Tracking Sheet revealed that the resident “has wounds to both thighs: (left posterior thigh and right posterior thigh).”

    The resident’s current Physician’s Order Sheet and Treatment Administration Record (TAR) documents “treatment ordered by [the resident’s] wound doctor dated July 6, 2017.” The doctor instructed the staff “to cleanse the wound on [the resident’s] right and left posterior thighs with wound cleanser and apply [a medication with dressing] to each area every three days and as needed.”

    However, an observation was made of the resident at 1:25 PM on July 17, 2017, while “seated in her wheelchair in her room. Upon standing, with the assistance of a Certified Nursing Assistant, the [surveyor noticed] dark red dried spots on the white sheet [that the resident] was sitting on. There was no [medicated] dressing in place to the open areas on the back of both of her thighs.” This observation “was verified by a Licensed Practical Nurse and the Certified Nursing Assistant.” The resident also stated at that time that “there were no dressings in place when they got me up this morning.”

    The facility was reminded that this was a deficiency by reviewing the nursing home’s Aseptic Wound Skin Treatment Procedure that reads in part:

    “To prevent contamination of the wound and protect the wound from mechanical injury. To stimulate, restore and promote circulation and healing. To prevent further deterioration of skin tissue, to prevent necrosis [dead tissue] of deeper body structures and promote resident comfort.”

    In a separate summary statement of deficiencies dated February 21, 2017, that investigator noted that the facility had failed to “ensure dressing supplies did not come in contact with potentially contaminated surfaces prior to performing a pressure ulcer dressing change for [a resident].”

    An observation was made of a resident at 5:00 AM on February 21, 2017, while “in bed waiting to have a soiled dressing to [the resident’s] right ischium [replaced] by [a Registered Nurse].” During the observation, it was noted that the resident’s “dressing supplies, including an open roll of gauze dressing was lying on top of [the resident’s] roommate’s bed.” The Registered Nurse “picked up the pair of scissors and the open roll of gauze from [the roommate’s] bed then cut off approximately 4 inches of gauze [before placing] the length of gauze on [the resident’s] bedside table without first cleansing the table.”

    The Registered Nurse (RN) then “moisten the gauze with medicated liquid, inserted the gauze into [the resident’s] stage IV right to ischium pressure ulcer, then covered the wound with the dry dressing.” The facility was reminded that this deficiency was a violation of the nursing home’s October 30, 2008, Dressing Change Policy that reads in part “to avoid introducing organisms into the wound, set up cleaning area for supplies.”

    In a different summary statement of deficiencies from three months prior on February 1, 2017, that investigator noted that the facility had failed to “follow policies and procedures and failed to implement pressure ulcer interventions for [two residents with pressure ulcers].” This failure by the nursing staff resulted in the resident “developing a new left heel pressure ulcer that deteriorated from a Stage II to an unstageable [bedsore] after it had developed.”

  • Failure to Develop, Implement and Enforce Programs That Investigate, Control and Keep Infections from Spreading

  • In a summary statement of deficiencies dated February 21, 2017, the state investigator noted the facility’s failure “to follow their infection control policy for transporting contaminated items for [one resident].” An observation was made of two Certified Nursing Assistants (CNA) assisting a resident on the morning of February 21, 2017 “from the commode to a wheelchair.”

    One Certified Nursing Assistant then “poured the urine and feces from the bedside commode collection container into a plastic bag and returned the commode collection container to the commode.” That CNA then “carried the bag from the commode, around the [resident’s] bed, and placed it in the isolation trash located in the corner of the room while passing with inches of [the resident’s] phone and drink sitting on the ‘over the bed’ table. The trash bag dripped several times during the transport. No one reentered the room during the next 30 minutes to clean.”

    An interview with the facility’s Director of Nursing twenty minutes later that same morning revealed that “on February 20, 2017, lab results showed [the resident] as ESBL (Extended Spectrum B-Lactamases and Escherichia Coli [E. Coli] of the urine” and that the resident “is in contact isolation.”

    The Director stated that the Certified Nursing Assistant “should have either taken the commode collection container to the dirty utility room for cleaning or take it into [the resident’s] bathroom for disposal and cleaning.” The Director also stated that the CNA “should not have disposed of the waste by carrying it across the room, dripping, to the isolation trash.”

  • Failure to Ensure a Register Nurse Was on Duty At Least Eight Hours Each Day

  • In a summary statement of deficiencies dated February 1, 2017, the state investigator noted that the facility failed to “ensure the services of a Registered Nurse for use for at least eight consecutive hours a day, seven days a week for 2 of 14” days reviewed for the survey. As part of the findings, resident was interviewed and while “lying in bed stated that the facility is short of staff at times and [it] can take over 45 minutes for the facility staff to respond to a call light.”

    A different resident was interviewed while sitting in a wheelchair [with their] call light on.” The resident stated that they were “waiting for the staff member to answer [their] call light so that [their] bed could be made because it had been stripped of linens early that morning.” The resident stated that “the facility is short staff at times, sometimes takes over 30 minutes per facility staff to respond to a call light, especially after lunch, before dinner and on the weekends.”

  • Failure to Report Investigate Any Act or Allegation of Abuse, Neglect or Mistreatment

  • In a summary statement of deficiencies dated January 13, 2017, the state investigator noted the facility had “failed to immediately intervene during active verbal abuse… to protect [a resident] and failed to immediately report an allegation and active abuse for [two residents].”

    A review of the facility’s Incident Investigation Form recorded by the Regional Administrative Consultant documents that a Certified Nursing Assistant (CNA) stated that his staff member told them they “had to scold [the resident because the resident] would not sit on the toilet right. During the documented interview, [the CNA] went to check on [the resident who] was upset and said [they] were too old to be scolded.”

    The CNA “stated she did not know she had to report the incident until after [they had] attended the Abuse/neglect ‘in-service’ later that morning.”

    In a separate incident, a review of the facility’s December 31, 2016, Abuse Report an Investigation Final Report by the facility Administrator revealed a report and investigation of verbal abuse reported by the housekeeper. The report revealed that the housekeeper “overheard a staff member who [the housekeeper thought] by the voice was [a specific Certified Nursing Assistant working in the facility who said] you are f****** nasty for sh***** in your diaper.”

    The housekeeper stated that they did not immediately respond to report the incident, but when returning home and after a discussion with the spouse returned the facility to report the incident to the facility’s Administrator. The housekeeper stated that the door had been closed but that they “did not open the door to intervene and protect the resident and stated, ‘I did not know what to do.’”

  • Failure to Develop, Implement and Enforce Policies and Prevent Mistreatment, Neglect or Abuse

  • In a summary statement of deficiencies dated January 13, 2017, the state investigator noted that the facility had failed to follow their abuse policy for two residents at the facility. The investigator reviewed the facility’s October 14, 2016, Abuse Prevention Program that affirms “the rights of the residents to be free from abuse.” Protecting the resident is to be done by: “Immediately protecting the resident involved in identified reports of possible abuse.” The report also states:

    “Employees are required to immediately report any occurrences a potential/allege mistreatment, neglect or abuse of residents.”

  • Failure to Develop, Implement and Enforce Programs That Investigate, Control and Keep Infection from Spreading

  • In a summary statement of deficiencies dated December 14, 2016, the State surveyor noted that the facility had failed to “ensure staff performs hand hygiene during medication administration for 40 [residents] during a medication pass.”

    A Registered Nurse stated during an interview that “I washed my hands with every procedure on each person during a medication pass, after Accucheck [t check blood sugar levels], and after injections. I should remove gloves before exiting the room. I realize I didn’t wash my hands and change my gloves as I should have. I should have worn gloves during an injection.”

    After a lengthy investigation and observations were made at the facility, the State surveyor interviewed the Director of Nursing on the morning of December 14, 2016. The Director stated that the staff member “should always watch her hands after coming in contact with anything potentially contaminated and hand sanitizer is available on the medication cards to use in situations where there is not gross contamination.

Was Your Loved One Injured or Abused in an Illinois Nursing Home?

If you were injured by neglect, abuse, or mistreatment, you are likely entitled to file a compensation case to receive monetary recovery for your damages. Consider hiring a personal injury attorney who specializes in abuse and mistreatment cases.

With legal representation, you can be assured that all your necessary documents are filed in the appropriate courthouse before the state’s statutes of limitations expire.

Nursing home abuse and neglect compensation claims are handled through contingency fee arrangements. These agreements allow immediate legal representation without the need for the plaintiff paying any upfront fees.

For more information on the laws and regulations applicable to Illinois nursing homes, look here.

If you are looking for a local attorney or for information on a nursing facility in a particular city, please visit the pages below:


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