Health inspection·November 1, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. R1 stated R1 knows it was 1:00PM as R1 stated she looked at the time due to having to wait a long time for her call light to be answered previously. R1 stated it was 3:00PM before staff came to change/clean her up. R1's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R1 is cognitively intact. R1's Care Plan dated 10/1/24 documents- Toilet Use: Two person physical assistance required. The same Care Plan documents R1 has a Self-Care Deficit as Evidenced by a recent hospitalization for weakness secondary to a diagnosis of Sepsis. The Care Plan documents R1 currently requires staff assistance for the completion of her ADL's (Activities of Daily Living). 2.) R2's admission Record printed on 11/1/24 at 12:14 PM documents R2 was admitted on [DATE] with a diagnoses of Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, Mild Protein-Calorie Malnutrition, Idiopathic Pulmonary Fibrosis, Spastic Hemiplegia, Panlobular Emphysema, Mild Intermittent Asthma With (Acute) Exacerbation, Irritant Contact Dermatitis Due To Fecal, Urinary or Dual, Incontinence, Laceration Without Foreign Body of Left Buttock, Bariatric Surgery Status, Zoster with other Complications, Hypothyroidism, Hyperlipidemia, Major Depressive Disorder, Anxiety Disorder, Insomnia, Obstructive Sleep Apnea, Disorders of Acoustic Nerve, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery, Angina Pectoris, Atrial Fibrillation, Diastolic (Congestive) Heart Failure, Allergic Rhinitis, Eosinophilic Esophagitis, Gastro-Esophageal Reflux Disease, Gout, Pain In Thoracic Spine, Chronic Kidney Disease, Stage 2, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia without Lower Urinary Tract, Tachycardia, Localized Edema, and Cachexia. Page 1 of 3 145691 145691 11/01/2024 Hallmark Healthcare of Pekin 2501 Allentown Road Pekin, IL 61554

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/1/24 at 10:45AM R2 was laying in his bed, R2 stated there are extended call light wait times, sometimes exceeding 30 minutes and he will call his wife for help who calls the facility to get someone to come help him. R2's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates R2 is cognitively intact. R2's Care Plan dated 4/1/2024 documents Self-Care Deficit as evidenced by recent hospitalization for diagnoses of urinary tract infection and Sepsis. The Care Plan documents R2 currently requires staff assistance for the completion of his ADL's (Activities of Daily Living). The same care plan dated 4/1/24 documents Toilet Use - One-person physical assist required. 3.) R3's admission Record printed on 11/1/24 at 12:43 PM documents R3 was admitted to the facility 2/28/2024 with diagnoses of Secondary Malignant Neoplasm, Spastic Hemiplegia Affecting Left Nondominant Side, Personal History of Transient Ischemic Attack (Tia), and Cerebral Infarction without Residual Deficits, Malignant Neoplasm of Lower Lobe, Right Bronchus or Lung, Mixed Hyperlipidemia, Dysphagia, Long Term (Current) use of Anticoagulants, Hypersomnia, Unilateral Primary Osteoarthritis, Right Hip, Sleep Apnea, personal history of Pulmonary Embolism, Basal Cell Carcinoma of Skin, Anxiety Disorder, Mild Protein-Calorie Malnutrition, Contracture, Left Hand, Major Depressive Disorder, and Local Infection of the Skin and Subcutaneous Tissue. On 11/1/24 at 1:00 PM R3 was escorted to the conference room and agreed to be interviewed. R3 stated call light times can be a very long wait sometimes greater than 30 minutes. R3's Minimum Data Set completed on Sep 25, 2024, documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R3 is cognitively intact. R3 Care Plan dated 3/1/2024 documents R3 has a Self-Care Deficit as evidenced by left sided spastic Hemiplegia secondary to a history of cerebral vascular accident, Osteoarthritis of the right hip, and weakness. The Care Plan documents R3 currently requires staff assistance for the completion of his ADL's (Activities of Daily Living). The same dated care plan documents Toilet Use: Two-person physical assistance required. 4.) R4's admission Record printed on 11/1/24 at 2:35 PM documents R4 was admitted to the facility 5/12/2023 with diagnoses of Essential (Primary) Hypertension, Allergic Rhinitis, Dependence on other enabling machines and devices, Allergy Status, Venous Insufficiency (Chronic), Sleep Apnea, Ventral Hernia without obstruction or Gangrene, Anxiety Disorder, Major Depressive Disorder, Glaucoma, Anemia, Vitamin D Deficiency, Body Mass Index [BMI]40.0-44.9, Morbid (Severe) Obesity, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Polyneuropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Atrioventricular Block, Hyperlipidemia, Atrial Fibrillation, Pleural Effusion, Hypotension, Presence of Cardiac Pacemaker, Pulmonary Fibrosis, Chronic Venous Hypertension (Idiopathic) with Ulcer of Left Lower Extremity, Insomnia, Type 2 Diabetes Mellitus with other Skin Complications, Bariatric Surgery Status, Gastro-Esophageal Reflux Disease without Esophagitis, Intestinal Adhesions [Bands], with Partial Obstruction, and Pressure Ulcer of Right Heel, Stage 4. On 11/1/24 at 2:15 PM R4 was sitting in the wheelchair at the bedside, R4 stated that it can take up to and over 30 minutes for his call light to be answered. 145691 Page 2 of 3 145691 11/01/2024 Hallmark Healthcare of Pekin 2501 Allentown Road Pekin, IL 61554

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R4's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R4 is cognitively intact. R4's Care Plan dated 8/22/2024 documents Self-Care Deficit as evidenced by: Needs (extensive) assistance with ADLs related to pain, weakness, lack of coordination, reduced mobility and abnormalities of gait and mobility. The Care Plan documents R4 currently requires staff assistance for the completion of his ADL's (Activities of Daily Living). On 11/1/24 at 10:30 AM V1 Administrator acknowledged the facility has extended call light wait times. On 11/1/24 at 11:13 AM V4 stated she is the SSD (Social Service Director) and one of her jobs is to talk to the residents. V4 stated she has received complaints from multiple residents about extended or long call light wait times. On 11/1/24 at 2:30 PM V2 Assistant Director of Nurses acknowledged the facility has extended call light times. V2 states they are working on it. Resident Council Minutes dated 10/7/24 document residents would like a quicker response time to call lights. The Call Light Guidance Policy: Issued Date: 9/22/20 Revised: 8/20/22 documents that resident call lights shall be responded to within a reasonable amount of time. 145691 Page 3 of 3