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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145691 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Healthcare of Pekin 2501 Allentown Road Pekin, IL 61554 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)