Hallmark Healthcare of Pekin

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 6, 2025

  Based 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. […]

• Actual harm, isolatedF690Jun 6, 2025

  Based 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. […]

• Actual harm, isolatedF692Jun 6, 2025

  Based 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). […]

• Actual harm, isolatedF600Dec 7, 2023

  Based 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. Findings include: The facility's Abuse policy dated 10/24/22 documents The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. […]

• Actual harm, isolatedF689Aug 24, 2023

  Based 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. Findings include: 1. On 8/21/23 at 11:54 am, R55 was sitting in a high back reclining wheelchair with a lap tray. R55 was non-verbal and leaning forward with her head resting on the lap tray. On 8/22/23 at 10:23 am, R55 was sleeping in bed with a staff member sitting in the doorway providing 1:1 supervision. […]