A list of the most recent deficiencies for Pekin Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-11-02 | 2023-11-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-02 | 2023-11-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-02 | 2023-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-11-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-02 | 2023-11-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-02 | 2023-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-02 | 2023-11-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-02 | 2023-11-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-02 | 2023-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-24 | 2023-08-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-08 | 2023-07-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-08 | 2023-07-17 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-28 | 2023-03-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-28 | 2022-10-13 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-09-28 | 2022-10-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-09-28 | 2022-10-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-28 | 2022-10-12 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2022-09-28 | 2022-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-18 | 2022-10-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-15 | 2022-10-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-15 | 2022-09-23 | N |
| 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. | Health | 2022-09-15 | 2022-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-18 | 2022-09-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-09-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-15 | 2022-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-09-22 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-08-25 | 2022-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-08-19 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-07-27 | 2022-08-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-25 | 2022-02-28 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-02-25 | 2022-02-28 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-02-25 | 2022-02-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-25 | 2022-02-28 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-01-18 | 2022-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-23 | 2022-01-26 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-02 | 2021-12-06 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-11-02 | 2021-12-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-02 | 2021-12-06 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-11-02 | 2021-11-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-02 | 2021-11-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-08 | 2021-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-10-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-08 | 2021-10-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-10-08 | 2021-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-08 | 2021-10-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-08 | 2021-10-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-08 | 2021-10-27 | N |
| 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. | Health | 2021-10-08 | 2021-10-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-08 | 2021-10-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-08 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-08 | 2021-10-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-08 | 2021-10-11 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-08 | 2021-10-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-08 | 2021-10-09 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-07-15 | 2021-07-27 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-15 | 2021-07-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-15 | 2021-07-27 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-15 | 2021-07-27 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-28 | 2021-05-12 | N |
