Hallmark Healthcare of Pekin

Inspectors wroteBased on record review and interview, the facility failed to ensure call lights were answered promptly for two of three residents (R1 and R2) reviewed for call lights in the sample of three.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's fall prevention safety alarm was maintained in proper working order for one of three residents (R3) reviewed for falls in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions for one of three residents (R1) reviewed for infection control in a sample of three. Findings Include:R1's current Physician Order Sheet documents, Enhanced Barrier Precautions related to indwelling (urinary) drainage catheter. On 9/16/25 at 1:40pm, R1 was in bed, with a urinary drainage bag hanging on the lower aspect of his bed frame. R1's urinary drainage bag contained approximately 400 milliliters of clear yellow urine. R1's door did not have a sign indicating EBP. On 9/17/25 at 10:00am, V4, Hospice Certified Nursing Assistant, was performing morning personal hygiene for R1. V4 then pushed R1 back to the main dining room. On 9/17/25 at 10:20am, V4 was unable to speak of the facility's Enhanced Barrier Precautions. [...]

Inspectors wroteBased on interview and record review the facility neglected to notify the physician and seek medical treatment after a significant decline in condition for one of three residents (R1) reviewed for neglect in the sample of nine. These failures resulted in R1 significantly declining in condition for two weeks before the facility sought medical treatment and sent R1 to the hospital on 5/10/25 for evaluation where R1 was admitted to the ICU (Intensive Care Unit) and remains in the hospital currently for treatment of Medical Neglect, Severe Dehydration, Acute Encephalopathy, Hypernatremia, Bladder Obstruction, Lactic Acidosis, Complicated Urinary Tract Infection, Sepsis, Metabolic Acidosis, Contractures to the Lower Extremities, and Bacterial Pneumonia. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on Interview and Record review, the facility failed to ensure a resident with diagnoses of Chronic Kidney Disease and Obstructive and Reflux Uropathy (urine flow obstruction) was monitored for urinary catheter obstruction, failed to document physician ordered urinary output, and provide indwelling urinary catheter changes every 30 days or as needed for one of three residents (R1) reviewed for urinary tract infections in a sample of nine. This failure resulted in R1 experiencing a significant change in condition and being sent to the local emergency room with a subsequent admission to the hospital's critical care unit for diagnoses including Acute Renal Failure, Bladder Obstruction, Complicated urinary Tract Infection, Lactic Acidosis and Metabolic Acidosis. This past noncompliance occurred from 4/29/25 through 5/13/25.

Inspectors wroteBased on interview and record review the facility failed to obtain physician ordered weekly weights and notify the Physician and Registered Dietitian of a resident's repetitive nutritional supplement refusals, decreased meal consumption, and significant weight loss for a resident with a diagnosis of Severe Protein-Calorie Malnutrition for one of three residents (R1) reviewed for weight loss in a sample of nine. These failures resulted in R1 experiencing a severe significant weight loss of 13.9 percent in less than six months and requiring admission to a local hospital critical care unit for treatment of the diagnoses of Hypernatremia, Acute Metabolic Encephalopathy, and Severe Malnutrition/concern for refeeding syndrome (Fatal Metabolic Response). This past noncompliance occurred from 4/29/25 through 5/13/25.

Inspectors wroteBased on Interview and Record review the facility failed to report an allegation of Injury of Unknown Origin to the facility's Abuse Coordinator and the State Agency for one of three residents (R4) reviewed for Injury of Unknown Origin in the sample of nine.

Inspectors wroteBased on Interview and Record Review, the facility failed to investigate an injury of unknown origin for one of three residents (R4) reviewed for Injuries of Unknown Origin in the sample of 9.

Inspectors wroteBased on Interview and Record review, the facility failed to ensure a resident was provided nursing assessments, vital signs, and timely provider notifications to ensure medical intervention was received with an acute change of condition for one of four residents (R4) reviewed for change of condition in the sample of nine.

Inspectors wroteBased on interview and record review, the facility failed to fully assess and complete a skin inspection assessment upon admission, obtain initial treatment orders upon admission, perform daily skin checks, and provide weekly documentation assessments for one (R1) of three residents reviewed for pressure ulcer/skin conditions in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident dignity was maintained by failing to ensure call lights were answered in a timely manner for four residents (R1, R2, R3 and R4) of four residents reviewed for call light response time in a sample list of four. Findings Include: 1.) R1's admission Record printed on 11/1/24 at 9:57 AM documents R1 was admitted to the facility 10/1/24 with diagnoses of Sepsis, Asthma, Obesity, Class 3, Essential (Primary) Hypertension, Chronic Kidney Disease, Stage 3, Localized Edema, Pneumonia, Chronic Right Heart Failure, Low Back Pain, Polycystic Kidney, Adult Type, Hypothyroidism, Irritable Bowel Syndrome, Pressure Ulcer of Other Site, Stage 2, and Neuromuscular Dysfunction Of Bladder. On 11/1/24 at 11:00 AM R1 stated on 10/26/24 at 1:00PM R1 pushed the call light as R1 had been incontinent of bowel at that time. [...]

Inspectors wroteBased on interview and record review, the facility failed to educate residents on what a grievance is, have grievance forms readily available in a public area in the facility, and allow a resident to file a grievance anonymously if desired. This has the potential to affect all 59 residents living in the facility.

Inspectors wroteBased on record review and interview the facility failed to implement their Abuse Policy to remove an alleged perpetrator from direct care of residents once an allegation of abuse was made by R7. This failure has the potential to affect all 59 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure direct care staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 59 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was in reach for one resident (R26) out of 15 residents reviewed for call lights in the sample 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nebulizer masks and nebulizer tubing were dated and stored in a bag between uses for two resident (R41 and R161), failed to ensure a resident had a physician order for oxygen for one resident (R2) and failed to ensure nasal cannula tubing were dated for two of six residents (R26 and R161) reviewed for respiratory care in a sample of 32.

Inspectors wroteBased on record review and interview the facility failed to implement their Abuse Policy to report staff-to-resident abuse to the administrator immediately for one of one resident (R7) reviewed for abuse reporting in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician ordered pressure relieving interventions for a resident identified as being a high risk for pressure ulcer development for one of three residents (R13) reviewed for pressure ulcers in the sample of 32. This failure resulted in R13 developing a painful, facility acquired stage four pressure ulcer to the left heel that became infected with MRSA (Methicillin Resistant Staphylococcus Aureus) and Proteus Mirabilis and required surgical debridement on multiple occasions.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician ordered scheduled medication from the pharmacy for one of fifteen residents (R2) reviewed for pharmacy services in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform anti-psychotic drug assessments, failed to perform gradual dose reductions, and failed to document behaviors and diagnosis to justify the use of an anti-psychotic medication for one of five residents (R38) reviewed for the use of anti-psychotic medication with the diagnosis of Dementia in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand and explain that the agreement must be rescinded within 30 days of signing the agreement. This has the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff follow safety precautions to prevent hand injury and failed to provide timely medical care for one resident (R1) reviewed for injury in a sample of three. These failures resulted in R1 sustaining pain and swelling in his right hand and being transported to the Emergency Department/ED.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (R8) out of three residents reviewed for abuse in a sample of eight. This failure resulted in R8 having feelings of being intimidated for prolonged periods of time.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and provide the sufficient staffing necessary to meet the needs of the residents. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent cross contamination of food products during meal service. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to complete their facility assessment to include the staffing requirements needed to care for the resident population and census. The facility also failed to review the facility assessments annually. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to have their call light answered in a timely manner for four residents (R1, R2, R4 and R5) reviewed for call lights in a sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to provide showers to four residents (R1, R2, R4 and R5) out of five residents reviewed for showers in sample of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to a cognitively impaired resident with a history of falling, for one of one resident reviewed (R55) for falls with major injury and failed to ensure a wandering resident did not enter other residents rooms for one of one resident (R29) in a sample of 56. This failure resulted in R55 falling from her wheelchair as she was unsupervised, on 8/06/23 and sustaining a left hip fracture.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure refrigerated foods were labeled with date opened, opened foods were stored in covered containers to prevent contamination, the kitchen floors were kept clean and free of debris, spills on the floor in the walk in cooler were cleaned, peeling paint was not hanging from the ceiling in food preparation areas, black spots were not covering the light fixture and ceiling above the ice machine, dust was not hanging from duct work over food preparation areas, and disinfectant used on the food preparation areas was the proper strength. These failures have the potential to affect all 56 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly dispose of garbage which has the potential to affect all 56 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct annual testing to rule out the presence of opportunistic waterborne pathogens in the facility's water system. This failure has the potential to affect all 56 residents currently residing in the facility. Findings Include: The facility's Legionella Water Management Program (revised July 2017) documents, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. A final report from a local water treatment company (dated 11/25/2020), documents the following result after the facility's water system was tested, Analytical Report, total Legionella- Not detected. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dining room ceiling tiles located directly over residents' dining tables were clean, free of dark stains and not bulging. This failure has the potential to affect all 56 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a wandering resident did not enter another resident's room without permission which affects two of 24 residents (R10, R29) reviewed for privacy in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's bathroom was clean for two of 24 residents (R10, R26) reviewed for a clean, homelike environment in a sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure oxygen tubing and nebulizer tubing was dated and stored in a bag between uses for one of one resident (R40) reviewed for respiratory care in a sample of 24.

Inspectors wroteBased on interview, observation and record review, the facility failed to identify target behaviors, document consistent adverse behaviors, attempt a gradual dose reduction, provide justification for duplicative therapy and justification for a dosage increase to warrant the continued use of an antipsychotic medication for three of four residents (R16, R30 and R55) reviewed for antipsychotic medications in the sample of 56.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a binding arbitration agreement was thoroughly explained and residents understood its meaning prior to obtaining a signature for two of three residents (R58, R59) reviewed for binding arbitration in a sample of 24. An Arbitration Tracking Log dated 6/2/23 to 8/22/23 documents that R58 and R59 were admitted to the facility on [DATE], and both accepted the binding arbitration agreement. R58 and R59's Electronic Agreement to Arbitrate Health Care Negligence Claims Notice to Patients forms dated 7/8/23, with electronic check marks in the acceptance box, documents both R58 and R59 signed the facility's arbitration agreement 7/8/23 which states, This agreement provides that any claims which may arise out of your health care will be submitted to a panel of arbitrators, rather than to a court for determination. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to develop a comprehensive care plan for two (R 27 and R 54) of 15 residents reviewed for care plans in a total sample of 24. Findings Include: Facility Care Planning policy, revised 7/14/22, documents To utilize the results of the comprehensive assessment to develop, revise, and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a care plan to include current pressure ulcers and interventions for one (R25) of 15 residents reviewed for care plan revision in a sample of 24.

Inspectors wroteBased on record review and interview, the facility failed to document circumstances requiring a discharge to the hospital and monitoring upon readmission for one resident (R14) of 3 residents reviewed for change of condition in a total sample of 24. Findings Include: The Facility's admission Procedure policy dated 5/17/22 documents It is the responsibility of all staff to ensure the needs of a new admission into the facility are met and the documentation is in place addressing the interventions utilized with in the time frame defined by CMS (Center for Medicaid and Medicare Services). The Facility's admission Procedure Policy documents When a resident is admitted to the nursing unit the admitting nurse must document the following information in the nurses' notes, admission form, or other appropriate place as designated by the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow occupational therapy's treatment plan to utilize an orthotic device to help prevent further contraction of the left hand for one resident (R54) of three residents reviewed for range of motion out of a sample of Findings Include: The facility's Restorative Program/Range of Motion policy revised 2/3/22 documents Purpose: To provide residents with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. R54's medical record documents R54 has a left-hand contracture. On 09/06/22 at 10:20 AM, observation of R54's left hand contracture. Resident can slightly open left hand. Upon R54 opening her left hand, it's observed that there's no device preventing R54's fingernails from coming in contact with her palm or to prevent further contracture. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to hang oxygen (O2) in use signage, document O2 titration, tubing and humidification bottle changes and failed to date O2 tubing for one (R155) of one resident reviewed for oxygen therapy in a sample of 15.

Inspectors wroteBased on record review and interview, the facility failed to identify and document specific behaviors necessitating the need for psychotropic medications for one resident (R41) of three residents reviewed for psychotropic medications in a total sample of 24. Findings Include: The Facility's Psychotropic Medications Policy dated 5/26/2022 documents In accordance with federal and state regulations, it is this facility's policy that residents will not be given unnecessary medications. The Facility's Psychotropic Medications Policy documents A behavior tracking record is used to keep record of resident's behaviors as required by federal regulations. The care plan will include objectives for gradual dose reduction as well as alternative interventions to assist in gradual dose reduction in accordance with Federal Regulations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain transmission-based precautions for two residents (R31, R41) of five residents reviewed for infection control in a total sample of 24.