Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pekin Manor during CMS and state inspections, most recent first.
Three residents developed severe pressure ulcers, including stage four wounds requiring surgical debridement, after the facility failed to conduct timely Braden risk assessments, update care plans with pressure-relieving interventions, and provide wound care as ordered by physicians. Staff were unaware of required interventions, and care plans did not reflect physician recommendations, resulting in missed treatments and lack of necessary pressure ulcer prevention measures.
Staff did not consistently use required gowns and gloves during wound and incontinence care for four residents with wounds or MDROs, despite facility policies and posted precautions. Observations showed the DON and other staff performing high-contact care without proper PPE, even when enhanced barrier or contact precautions were indicated.
A resident who required assistance for incontinence care and dressing was left in bed with a soiled brief and gown for an extended period after her call light was not answered in a timely manner. A CNA turned off the call light without providing care, and the resident, who could not get up independently due to a knee brace, expressed embarrassment over the situation. Facility policies require prompt response to call lights and maintenance of resident dignity, which was not followed in this instance.
A resident with advanced dementia fell and sustained serious injuries after her walker became entangled in a loose bed remote cord on the floor. The incident occurred while she was being assisted to the bathroom by a CNA. The unsecured cord, which belonged to her roommate's bed, had become a trip hazard after the bed was moved. The fall resulted in a forehead laceration, a skin tear, and fractures to the C1 and C2 vertebrae.
A resident with an indwelling catheter was observed in the dining room with an uncovered urinary drainage bag, compromising their dignity. The resident, who believed the bag was covered, expressed a desire for it to be concealed. A nurse confirmed the oversight, and the DON stated that covering catheter bags is standard practice, despite the absence of a formal policy.
The facility failed to notify the Ombudsman of transfers for two residents, leading to a deficiency. One resident with multiple diagnoses was transferred to the hospital twice in June for a UTI and sepsis, but these were not documented in the monthly report. Another resident with chronic conditions was transferred in January for a UTI, also not documented. The Social Services representative confirmed the omissions despite the information being entered into the system.
A resident with multiple diagnoses, including CHF, did not have a timely care plan for their anticoagulant medication as required by the facility's policy. The resident's MDS assessment indicated anticoagulant use, and a physician's order for Eliquis was documented, but the care plan was not created until much later. This delay was confirmed by the MDS/Care Planner, highlighting a failure to adhere to the facility's care plan policy.
A facility failed to change a resident's oxygen tubing and humidifier bottle weekly, as required by their policy. The resident, with multiple respiratory conditions, was observed using an oxygen setup with a humidifier bottle dated over a month prior. This was confirmed by a nurse and the DON, who acknowledged the policy of weekly changes.
A facility failed to document a diagnosis and monitor behaviors to justify antipsychotic medication for a resident. The resident's record showed Quetiapine use for unspecified Alzheimer's, but observations indicated cooperation and no adverse behaviors. Staff confirmed the absence of behaviors or diagnosis warranting the medication, noting only increased evening confusion that was easily redirected.
Failure to Prevent and Treat Pressure Ulcers Due to Inadequate Assessment and Care Planning
Penalty
Summary
The facility failed to develop and implement appropriate pressure ulcer prevention and care interventions for three residents, resulting in the development and worsening of pressure ulcers. Specifically, the facility did not conduct required Braden Scale Pressure Ulcer Risk Assessments weekly for the first four weeks after admission and quarterly thereafter, as outlined in their own protocol. For each of the three residents reviewed, there were significant lapses in risk assessment documentation, with only a single Braden assessment completed in the past year for some residents, and no assessments after changes in condition or as required by policy. Additionally, the facility did not update or implement individualized care plans with necessary pressure-relieving interventions, such as the use of heel protector boots, low air-loss mattresses, or turning and repositioning schedules, even when residents were identified as being at risk or after physician orders were given. Observations revealed that residents with existing pressure ulcers were not provided with ordered pressure-relieving devices, and staff were unaware of the need for these interventions. In several cases, care plans did not reflect physician recommendations or orders for pressure ulcer prevention and treatment, and staff failed to ensure that interventions such as off-loading heels or using special mattresses were in place. The facility also failed to provide wound care treatments as ordered by physicians, with documented instances where scheduled treatments were missed. As a result of these failures, residents developed severe, facility-acquired pressure ulcers, including stage four ulcers that required surgical debridement. Interviews with staff and review of records confirmed that the lack of timely assessments, incomplete care planning, and failure to implement or follow physician orders directly contributed to the development and progression of pressure ulcers in these residents.
Failure to Implement Enhanced Barrier and Contact Precautions During Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and contact precautions during wound and incontinence care for four residents who required these infection control measures. According to the facility's policies, staff are required to use gowns and gloves during high-contact care activities, such as wound care and incontinence care, especially for residents with wounds, indwelling devices, or infections/colonization with multidrug-resistant organisms (MDROs). Despite these requirements, direct observations revealed that the Director of Nursing (DON) did not wear a gown while performing wound treatments on three residents, all of whom had wounds and/or MDROs and had EBP or contact precautions signage posted on their doors. Additionally, a CNA assisted with wound care and urinal use for one resident without wearing gloves. Another incident involved a resident with a buttock wound and significant fecal incontinence, where both the LPN and CNA providing incontinence care did not wear gowns, despite EBP signage and physician orders indicating the need for these precautions. Interviews confirmed that staff were aware of the requirement to use gowns and gloves during these care activities but failed to do so during the observed events. The deficiencies were identified through observation, interview, and record review, and involved residents with documented needs for EBP or contact precautions due to wounds or MDROs.
Failure to Respond Timely to Call Light and Provide Dignified Incontinence Care
Penalty
Summary
A resident who required one-person assistance for incontinence care was observed lying in bed with a soiled adult brief and gown, with feces present on her legs and stomach. The resident's call light was on, and she reported having waited for over half an hour for assistance to be cleaned and dressed. She stated that she had activated her call light more than two hours earlier to request help getting out of bed and dressed for the day. A CNA entered the room earlier, turned off the call light, and stated she would return, but did not come back to assist the resident. The resident, who had a knee brace and was unable to get up or dress independently, expressed embarrassment about her situation. The facility's policies require prompt response to call lights and emphasize treating residents with dignity and respect. The CNA acknowledged that she was passing meal trays when the resident requested help and did not have time to assist, so she turned off the call light without providing the needed care. The Director of Nursing confirmed that the resident should not have been left in this condition and that the call light should have been answered more quickly.
Resident Falls Due to Trip Hazard from Unsecured Cord
Penalty
Summary
The facility failed to ensure the floor was free from trip hazards, leading to a fall incident involving a resident. The incident occurred when a resident, who was being assisted by a CNA with a walker and gait belt, tripped over a cord from a bed remote that was lying on the floor. The cord became entangled in the wheel of the resident's walker, causing her to lose balance and fall. This fall resulted in significant injuries, including a laceration to the forehead requiring nine sutures, a skin tear and bruising to the right third finger, and fractures to the C1 and C2 vertebrae. The resident involved in the incident had a history of advanced dementia and was under hospice care. At the time of the fall, she was being assisted to the bathroom by a CNA. The cord that caused the fall was from the bed remote of the resident's roommate, who could not utilize the remote due to dementia. The cord had become unsecured when the roommate's bed was moved back into the room a day or two before the incident. The fall was witnessed by the assisting CNA, who immediately called for help. The resident was assessed by a nurse and subsequently transported to a local emergency department for further evaluation and treatment. The incident highlights a failure in maintaining a safe environment free from accident hazards, as the unsecured cord posed a significant risk that led to the resident's fall and subsequent injuries.
Failure to Cover Urinary Catheter Bag with Privacy Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not covering a urinary catheter bag with a privacy bag. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and had an indwelling catheter, was observed in the dining room with the urinary drainage bag visibly uncovered. The resident expressed a preference for the bag to be covered, indicating she thought it was already covered. A registered nurse confirmed the bag was not covered, and the Director of Nursing acknowledged that while there was no formal policy, covering catheter bags with a privacy bag was standard practice.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the facility Ombudsman of discharges and transfers for two residents, leading to a deficiency in compliance with notification requirements. The first resident, identified as R26, was admitted to the facility with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Vascular Dementia. R26 was transferred to the hospital twice in June 2024, once for a urinary tract infection and once for sepsis, but these transfers were not documented in the facility's Admit/Discharge Report for that month. The Social Services representative acknowledged that R26 was not included in the list provided to the Ombudsman, despite the information being entered into the system. Similarly, the second resident, identified as R67, was admitted with conditions such as Chronic Kidney Disease Stage 3 and Chronic Systolic Heart Failure. R67 was transferred to the hospital in January 2024 for a urinary tract infection but was not documented in the January 2024 Admission/Discharge Log. The Social Services representative also confirmed that R67 was not included in the list sent to the Ombudsman, even though the information was reportedly entered into the system. These omissions indicate a failure in the facility's process for ensuring timely and accurate notification of resident transfers to the Ombudsman.
Failure to Develop Timely Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a Person-Centered Care Plan for a resident, identified as R67, who was part of a sample of 33 residents reviewed for care plans. The facility's Care Plan Policy mandates the development and implementation of a comprehensive care plan within seven days after the completion of the comprehensive Minimum Data Set (MDS) assessment. This care plan should include measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. However, R67, who was admitted with multiple diagnoses including Chronic Kidney Disease Stage 3, Sepsis, Anxiety, Essential Hypertension, and Chronic Systolic Heart Failure, did not have a care plan for their anticoagulant medication until much later than required. R67's MDS assessment, dated January 20, 2024, indicated the use of an anticoagulant, and a physician's order for Eliquis 5 mg twice daily was documented with a start date of January 13, 2024. Despite this, the care plan for the anticoagulant was not documented until September 24, 2024. This delay was confirmed by the MDS/Care Planner, who acknowledged that there should have been a care plan in place for the anticoagulant medication earlier. This oversight indicates a failure to adhere to the facility's policy for timely development of a comprehensive care plan, potentially impacting the resident's care management.
Failure to Change Oxygen Tubing and Humidifier Bottle Weekly
Penalty
Summary
The facility failed to adhere to its Oxygen Therapy policy, which mandates that oxygen setup, including cannula/mask and tubing, must be exchanged every seven days. This deficiency was observed in the case of a resident who was admitted with multiple respiratory conditions, including Acute Respiratory Failure with Hypoxia, COPD, and Chronic Respiratory Insufficiency. The resident's care plan required oxygen therapy at three liters per minute. During an observation, it was noted that the humidifier bottle connected to the resident's oxygen setup was dated over a month prior, indicating it had not been changed weekly as required. This was confirmed by a registered nurse and the Director of Nursing, both of whom acknowledged the policy of weekly changes and the requirement for staff to date the tubing and humidifier bottle upon replacement.
Failure to Justify Antipsychotic Use for a Resident
Penalty
Summary
The facility failed to document a diagnosis and monitor specific adverse behaviors to justify the use of antipsychotic medication for one resident reviewed for unnecessary medications. The facility's Psychopharmacological Drug Usage Procedure requires routine documentation of behaviors and conditions necessitating these medications, as well as monitoring medication response and adverse consequences. The resident's Medication Administration Record indicated the use of Quetiapine, an antipsychotic, for Alzheimer's disease, unspecified. Observations over several days showed the resident was cooperative with care and often sleeping in a wheelchair, with no signs of adverse behaviors. A Certified Nursing Assistant confirmed the resident did not exhibit adverse behaviors, and the Assistant Director of Nursing verified the absence of a diagnosis or behaviors warranting antipsychotic use, noting only increased confusion in the evenings that was easily redirected.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pekin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmark Healthcare Of Pekin | 1.5 mi | ★★★★★ | 1 | 0 |
| Timbercreek Rehab And Health Care Center | 2.3 mi | ★★★★★ | 10 | 1 |
| Arcadia Care Morton | 9 mi | ★★★★★ | 15 | 0 |
| Apostolic Christian Restmor | 10.1 mi | ★★★★★ | 1 | 0 |
| Fondulac Rehabilitation And Health Care Center | 10.7 mi | ★★★★★ | 4 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.