Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hallmark Healthcare Of Pekin during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter did not have Enhanced Barrier Precautions (EBP) implemented as required. Staff provided personal care using only gloves and a mask, without donning gowns or following EBP protocols, and there was no EBP signage or isolation cart outside the room. The facility's policy required EBP for residents with indwelling devices, but these measures were not followed.
A resident with multiple chronic conditions experienced a significant decline over two weeks, including severe dehydration, weight loss, and decreased responsiveness. Despite clear signs of deterioration, staff did not notify the physician or update the care plan, and failed to monitor fluid intake, weight, and catheter care as required. The resident was eventually hospitalized in critical condition with multiple life-threatening complications, and hospital staff documented evidence of prolonged neglect.
A resident with chronic kidney disease and an indwelling urinary catheter was not properly monitored for catheter obstruction, and required documentation of urinary output and catheter changes was not completed as ordered by the physician. Staff failed to report and document changes in the resident's condition, including decreased urine output and altered mental status. The resident was ultimately hospitalized with acute renal failure, bladder obstruction, and a complicated UTI, with hospital staff noting poor catheter care and severe dehydration.
A resident with severe protein-calorie malnutrition, dementia, and diabetes experienced a 13.9% weight loss over six months due to the facility's failure to obtain weekly weights as ordered, lack of documentation and monitoring of nutritional supplement intake, and failure to notify the physician and dietitian of ongoing meal refusals and declining intake. The care plan was not updated to address these issues until just before the resident was hospitalized in a severely malnourished and dehydrated state.
A resident was transferred to the hospital for increased confusion and lethargy, where a CT scan revealed a new head bleed suspected to be from an unwitnessed fall. Nursing staff notified the DON, but no incident report, investigation, or state agency notification was completed, despite facility policy requiring such actions for injuries of unknown origin.
A resident was transferred to the hospital where a CT scan revealed internal bleeding of unknown origin. Despite being notified by the family that the injury may have resulted from an unwitnessed fall, staff did not initiate an incident report or conduct an investigation, and no report was made to the state agency. Facility policies requiring investigation and documentation of such incidents were not followed.
A resident with multiple chronic conditions experienced a sudden decline, including confusion, lethargy, and inability to self-feed, but staff failed to perform or document nursing assessments, vital signs, or neurological checks, and did not ensure timely provider notification. The LPN relied solely on fax to contact the provider and did not escalate when no response was received, resulting in delayed medical intervention until the resident was eventually sent to the hospital and diagnosed with a brain bleed.
A resident admitted with multiple comorbidities and a stage 3 pressure ulcer did not receive a complete skin inspection assessment or timely treatment orders upon admission. Required daily skin checks and weekly documentation were not performed, and the wound was not properly documented or treated until two weeks after admission, as confirmed by the DON and Administrator.
The facility failed to respond to call lights in a timely manner, affecting four residents who reported extended wait times, sometimes exceeding 30 minutes. These residents, who are cognitively intact, require assistance for activities of daily living due to various medical conditions. The administration acknowledged the issue, and the Resident Council expressed a desire for quicker response times.
The facility did not educate residents on grievances, lacked publicly available grievance forms, and did not allow anonymous submissions. Residents were unaware of these processes, and the administrator admitted to not implementing the facility's grievance policy, which allows for anonymous complaints. The facility houses 59 residents.
A cognitively intact resident alleged that a CNA yanked her arm, causing shoulder pain. Despite reporting the incident to an RN, the CNA was not removed from resident care and continued working. The RN, new to the facility, was not trained on the abuse policy, which requires immediate removal of staff suspected of abuse. This failure potentially affected all 59 residents.
The facility did not provide annual QAPI training to direct care staff, as confirmed by the Administrator and evidenced by the absence of such training in the Annual Training Logs. This deficiency could affect all 59 residents in the facility.
A resident with multiple health conditions, including COPD and diabetes, was found without a call light within reach while in a wheelchair with oxygen. The CNA discovered the call light on the floor, and the DON confirmed it should have been accessible, as per facility policy.
The facility failed to properly manage respiratory care equipment for several residents, including undated oxygen tubing and nebulizer masks not stored in bags. A resident was using oxygen without a physician's order, and staff confirmed that equipment should be changed weekly and labeled, as per facility policy.
A cognitively intact resident reported that a CNA was rough and hurt her shoulder during care. The allegation was communicated to an RN and another CNA, but neither reported it to the administrator as required by the facility's Abuse Policy. The RN, who had been employed for three weeks, claimed she was not trained on the abuse policy and did not report the incident, assuming it was a racial issue. However, the administrator confirmed that the RN had received abuse training earlier in the month.
A resident at high risk for pressure ulcers developed a stage four ulcer on the left heel due to the facility's failure to implement physician-ordered interventions. Despite being cognitively intact and having a care plan that included heel floating devices and repositioning, the resident's heels were often left on the mattress without pressure relief. Staff were unaware of the orders for pressure-relieving boots, leading to the ulcer becoming infected and requiring surgical debridement.
A resident did not receive a physician-ordered medication, Cyclobenzaprine Hydrochloride, due to the facility's failure to obtain it from the pharmacy. The LPN administering medications was aware of the issue but did not notify the resident's doctor. The resident missed six doses over two days, and the DON confirmed the medication was not given, highlighting a breach in the facility's policy on handling unavailable medications.
A facility failed to conduct necessary assessments and documentations for a resident on anti-psychotic medication. Despite the resident's diagnosis of dementia and regular Seroquel use, there were no attempts at gradual dose reduction or physician documentation for contraindications. Observations and interviews indicated no behaviors justifying the medication, and the resident expressed a desire to reduce medication due to tiredness.
The facility failed to properly explain the arbitration agreement to residents or their representatives, leading to misunderstandings about waiving the right to sue. Interviews revealed that residents and their representatives were not informed about the 30-day rescission period and were unaware of the agreement's implications. The administrator acknowledged the lack of a policy on this matter.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as required by their infection prevention and control program. The resident's physician order sheet documented the need for EBP due to the presence of a urinary drainage catheter. During observation, the resident was found in bed with a urinary drainage bag, but there was no EBP sign on the door, and no isolation cart was present outside the room. Staff interviews revealed that the hospice certified nursing assistant providing personal care to the resident only wore gloves and a mask, and was unaware of the facility's EBP requirements. The assistant director of nursing confirmed that residents with indwelling urinary catheters should be on EBP, with appropriate signage and equipment in place, which was not observed for this resident. The facility's policy, revised on 12/10/24, specifies that EBP should be used in conjunction with standard precautions, including donning gowns and gloves during high-contact care activities for residents with indwelling medical devices. The policy also outlines the specific care activities and situations where EBP is indicated. Despite these requirements, the staff did not follow the policy for the resident with a urinary catheter, as evidenced by the lack of signage, equipment, and proper use of personal protective equipment during care.
Failure to Notify Physician and Provide Timely Medical Care Results in Resident Harm
Penalty
Summary
A significant deficiency occurred when facility staff failed to notify the physician and seek medical treatment for a resident who experienced a marked decline in condition over a two-week period. Despite clear signs of deterioration, including decreased oral intake, weight loss, increased weakness, and changes in behavior, staff did not document or communicate these changes to the resident's physician or dietitian. The facility's own policies required prompt recognition and reporting of acute changes in condition, but these were not followed. Multiple staff interviews confirmed that although the resident's decline was observed and discussed among staff and with family, no physician notification or medical intervention was initiated during this period. The resident, who had a history of multiple chronic conditions including diabetes, malnutrition, chronic kidney disease, and obstructive uropathy with an indwelling urinary catheter, was not properly monitored for fluid intake, weight, or catheter care. Documentation revealed missed weekly weights, inconsistent meal consumption records, and a lack of monitoring of urinary output. The care plan was not updated to address the resident's rapid weight loss, decreased intake, or increased risk for infection and contractures until just before the resident was sent to the hospital. Staff failed to change the resident's urinary catheter as ordered, and there was no evidence of physician notification regarding the resident's significant decline or catheter-related issues. When the resident was finally sent to the hospital, he was found to be in critical condition, suffering from severe dehydration, acute encephalopathy, hypernatremia, bladder obstruction, lactic acidosis, complicated urinary tract infection, sepsis, metabolic acidosis, contractures, and bacterial pneumonia. Hospital staff documented evidence of poor hygiene, inadequate oral and catheter care, and severe malnutrition. The admitting hospital physician and nurse both noted that the resident's condition indicated prolonged neglect, and the facility's failure to provide necessary medical care and monitoring resulted in the resident's admission to the ICU for treatment of multiple life-threatening conditions.
Failure to Monitor and Document Catheter Care Leading to Resident Hospitalization
Penalty
Summary
A resident with chronic kidney disease, obstructive and reflux uropathy, and benign prostatic hyperplasia was not properly monitored or cared for in relation to their indwelling urinary catheter. The facility failed to monitor for catheter obstruction, did not document physician-ordered urinary output every shift, and did not perform required catheter changes every 30 days or as needed. Documentation was missing for multiple shifts regarding urine output, and there was no record of catheter changes for several months, despite physician orders and facility policy requiring these actions. The resident's care plan identified high risk for urinary tract infection due to catheter use and included interventions such as monitoring intake and output, observing for signs of infection, and changing the catheter and drainage bag per physician orders. However, nursing progress notes and treatment administration records showed gaps in documentation of urine output and catheter changes. Staff interviews revealed that changes in the resident's condition, such as decreased activity, reduced urine output, and changes in urine color, were either not reported to the physician or not documented. The LPN responsible did not notify the physician of the resident's decline, and abnormal lab results were not promptly communicated to the physician, resulting in delayed treatment. The resident was eventually sent to the emergency room after exhibiting severe symptoms, including lethargy, hypotension, and purulent drainage from the catheter. Hospital records indicated the resident had acute renal failure, bladder obstruction, complicated urinary tract infection, and severe dehydration. The hospital staff noted poor catheter care, excoriation, and lack of cleanliness around the catheter site. The facility's failure to follow physician orders, monitor and document catheter care, and respond to changes in the resident's condition led to a significant decline in the resident's health and subsequent hospitalization.
Failure to Monitor and Report Significant Weight Loss and Nutritional Decline
Penalty
Summary
A facility failed to obtain physician-ordered weekly weights and did not notify the physician or registered dietitian of a resident's repeated refusals of nutritional supplements, decreased meal consumption, and significant weight loss. The resident, who had a diagnosis of severe protein-calorie malnutrition, dementia, and type 2 diabetes with chronic kidney disease, experienced a 13.9% weight loss in less than six months. Documentation showed that weekly weights were not consistently recorded as ordered, and there was a lack of documentation regarding the amount of nutritional supplement consumed. The resident's meal intake was also inconsistently documented, with frequent low consumption and multiple meal refusals over an eleven-day period. Despite clear evidence of declining intake and significant weight loss, there was no documentation that the physician or dietitian was notified of these changes. The care plan was not revised to address the resident's rapid weight loss, decreased meal consumption, or supplement refusals until two days before the resident was hospitalized. Interviews with staff confirmed that they observed the resident's decline, including decreased activity, poor intake, and refusal to eat or drink, but did not notify the physician or dietitian as required by facility policy. The resident was eventually admitted to a hospital in a severely malnourished and dehydrated state, with diagnoses including hypernatremia, acute metabolic encephalopathy, and severe malnutrition with concern for refeeding syndrome. Hospital staff and the admitting physician noted the resident's poor condition and indicated that the decline had been ongoing for days prior to admission. Facility staff and the director of nursing confirmed that required notifications and care plan updates were not completed in a timely manner.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for one resident, as required by both facility policy and regulatory guidelines. A resident was noted to have increased confusion and lethargy, leading to a transfer to the emergency department. Later, the resident's family informed facility staff that a CT scan at the hospital revealed internal bleeding in the head, which the hospital indicated could be from a possible unwitnessed fall. Nursing staff reviewed records and found no documented falls or incidents in the prior 24 hours. The nurse on duty notified the Director of Nursing (DON) about the new information from the family, but no written investigation or incident report was completed, and the event was not reported to the state agency. The facility's policies require that all accidents and incidents, including injuries of unknown origin, be reported to the department supervisor, documented with an incident report, and reported to the abuse coordinator and state agency. Despite these requirements, the DON confirmed that no investigation or report was made because the source of the injury was unknown and there were no documented falls. The administrator, who serves as the abuse coordinator, was not informed of the injury until after reviewing the nursing note and acknowledged that the incident should have been identified and investigated as an injury of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was transferred to the emergency department and subsequently to a tertiary hospital, where a CT scan revealed internal bleeding. Nursing notes indicated that the resident had not experienced any documented falls or incidents in the 24 hours prior to the injury, and the last recorded fall occurred several days earlier without head trauma. Despite being informed by the resident's family that the hospital identified a new head bleed possibly due to an unwitnessed fall, staff did not initiate an incident report or conduct an investigation into the cause of the injury. Interviews with facility staff, including the LPN, DON, and Administrator, confirmed that no written investigation or report to the state agency was completed regarding the injury. The facility's own policies require that all accidents and incidents, including injuries of unknown origin, be reported, investigated, and documented, but these procedures were not followed in this case. The Administrator, who serves as the facility's Abuse Coordinator, acknowledged that the incident should have been identified and investigated as an injury of unknown origin, but this was not done.
Failure to Assess and Notify Provider During Acute Change in Condition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including atrial fibrillation, hypertension, diabetes, Parkinson's disease, congestive heart failure, and Lewy Body dementia, experienced an acute change in condition that was not properly assessed or managed by facility staff. The resident, who was typically able to feed himself with only setup help or cuing, became suddenly confused, lethargic, and unable to eat independently. Family members and another resident observed these significant changes, noting that the resident was not making sense and could not pick up his fork at lunch, which was a marked departure from his baseline. Despite these clear signs of acute deterioration, the nursing staff did not perform or document a nursing assessment, vital signs, or neurological checks on the day of the incident. The last recorded assessment and vital signs were from the previous day, and there was no evidence of timely provider notification or response. The assigned LPN recognized the change in the resident's condition around mid-morning, notified the family, and attempted to contact the provider by fax, but did not follow up with a phone call or escalate the situation when no response was received. The resident's condition remained unchanged for several hours before being sent to the emergency department. Upon arrival at the hospital, the resident was found to have a fresh brain bleed and was transferred to a higher level of care for neurosurgical evaluation and blood pressure management. The facility's own policy required prompt assessment, collection of pertinent information, and direct communication with providers in the event of an acute change of condition, but these steps were not followed. The Director of Nursing confirmed that the expected assessments and provider notifications were not completed during the critical period when the resident was exhibiting significant new deficits.
Failure to Assess and Treat Pressure Ulcer Upon Admission
Penalty
Summary
The facility failed to fully assess and document a pressure ulcer for a resident upon admission, as well as to obtain timely treatment orders and perform required ongoing assessments. The resident, who was admitted with multiple significant diagnoses including gangrene, diabetes, muscle wasting, and a recent above-the-knee amputation, was identified as high risk for pressure ulcers. Upon admission, an open area on the sacrum was noted, and the care plan documented a stage three pressure injury to the coccyx. However, there was no completed skin inspection assessment at admission, and no initial treatment orders were obtained for the pressure ulcer until 14 days after admission, when a nurse practitioner evaluated the wound and provided treatment recommendations. Additionally, the facility did not perform daily skin checks or provide weekly documentation assessments for the pressure ulcer as required by policy. Although weekly skin inspections were signed off on the Treatment Administration Record, there was no corresponding documentation in the medical record regarding the status of the pressure ulcer prior to the late treatment order. The Director of Nursing and Administrator confirmed these omissions, acknowledging the lack of assessment, documentation, and timely intervention for the resident's pressure ulcer.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to maintain resident dignity by not responding to call lights in a timely manner for four residents. Resident 1 reported a significant delay in response time, waiting two hours for assistance after being incontinent. This resident, who is cognitively intact with a BIMS score of 15, requires two-person assistance for toileting due to a self-care deficit related to recent hospitalization and weakness from sepsis. Resident 2 also experienced extended call light wait times, sometimes exceeding 30 minutes, and resorted to calling his wife for help. This resident, with a BIMS score of 13, requires one-person assistance for toileting due to a self-care deficit following hospitalization for a urinary tract infection and sepsis. Similarly, Resident 3 and Resident 4 reported waiting over 30 minutes for call light responses. Both residents are cognitively intact with BIMS scores of 15 and require staff assistance for activities of daily living due to various medical conditions. The facility's administration, including the Administrator and Assistant Director of Nurses, acknowledged the issue of extended call light wait times. The Social Service Director also confirmed receiving multiple complaints from residents about the delays. The Resident Council Minutes further documented the residents' desire for quicker response times. The facility's Call Light Guidance Policy states that call lights should be answered within a reasonable time, indicating a failure to adhere to this policy.
Failure to Educate and Provide Grievance Forms
Penalty
Summary
The facility failed to educate residents on the concept of a grievance, did not have grievance forms readily available in a public area, and did not allow residents to file grievances anonymously. During a group meeting, several residents expressed that they were unaware of what a grievance was, where to find forms, how to file one, and that it could be done anonymously. The residents indicated an interest in having these options available for future use, with one resident specifically mentioning the desire to report issues without revealing their identity. The facility's administrator acknowledged that residents are encouraged to report issues to staff, but they refer to them as concerns rather than grievances. The administrator also admitted that grievance forms were not displayed for residents or families to fill out and had not considered the possibility of anonymous submissions. The facility's grievance policy, dated 2019, states that individuals have the right to file grievances or complaints anonymously, but this was not being implemented. The facility currently houses 59 residents.
Failure to Remove Alleged Perpetrator Following Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Policy by not removing an alleged perpetrator from direct care of residents following an abuse allegation. A Certified Nursing Assistant (CNA) was accused by a resident, who is cognitively intact, of yanking her arm and causing shoulder pain. Despite the report of this incident to a Registered Nurse (RN) on the same day, the CNA was not removed from resident care and continued to work until the end of her shift. The RN, who had only been employed at the facility for three weeks, admitted to not being trained on the abuse policy. The facility's policy mandates that any staff member suspected of abuse should be escorted out of the facility and not allowed to return until the investigation is complete. However, this procedure was not followed, as the CNA continued to provide care to residents, including the one who made the allegation. The facility's documentation confirms that 59 residents were residing in the facility at the time, potentially putting all at risk due to the failure to adhere to the abuse policy.
Lack of QAPI Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff received annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's Annual Training Logs, which lacked evidence of QAPI training for employees. During an interview, the Administrator confirmed that the facility does not conduct QAPI training for any staff and does not have a policy in place for providing such training. This oversight has the potential to impact all 59 residents currently residing in the facility, as documented in the facility's CMS Long Term Care Facility Application for Medicare and Medicaid Form 671.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The resident, who was admitted with multiple diagnoses including COPD, chronic respiratory failure, emphysema, hypertension, chronic kidney disease, and type 2 diabetes mellitus, was observed sitting in a wheelchair with oxygen but without the call light in reach. The resident reported not having the call light since being assisted out of bed by staff. A CNA later found the call light on the floor near the head of the resident's bed, confirming it was not accessible. The Director of Nursing acknowledged that the call light should always be within reach, as per the facility's policy dated 8/20/24.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, as evidenced by undated and improperly stored respiratory equipment. For one resident, oxygen tubing was not dated, and the resident was unsure of how often it was changed. The Director of Nursing confirmed that oxygen tubing should be changed weekly and labeled with the date. Another resident had undated oxygen tubing and a nebulizer mask and tubing that were not stored in a bag, contrary to facility policy. The Director of Nursing stated that nebulizer tubing should be labeled, and the mask should be stored in a plastic bag when not in use. Additionally, a resident was found using oxygen without a physician's order, and the nasal cannula tubing was undated. The Director of Nursing was unaware of why there was no order for the resident to wear oxygen, despite the resident always having it on. Another resident's nebulizer tubing and mask were also undated and unbagged, which was verified by a Licensed Practical Nurse who acknowledged that the equipment should be changed weekly and stored properly. These deficiencies highlight a lack of adherence to the facility's policies on respiratory care equipment management.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Policy by not reporting staff-to-resident abuse allegations to the administrator immediately. A resident, who is cognitively intact, reported that a CNA was rough and hurt her shoulder during care. This allegation was communicated to an RN and another CNA, but neither reported it to the administrator as required by the facility's policy. The RN, who had been employed for three weeks, claimed she was not trained on the abuse policy and did not report the incident, assuming it was a racial issue. However, the administrator confirmed that the RN had received abuse training earlier in the month. The facility's policy mandates that all staff report any allegations of abuse immediately to the administrator.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement physician-ordered pressure-relieving interventions for a resident identified as high risk for pressure ulcer development. The resident, who was cognitively intact and had severely limited mobility, developed a painful, facility-acquired stage four pressure ulcer on the left heel. This ulcer became infected with MRSA and Proteus Mirabilis, requiring multiple surgical debridements. The resident's care plan included interventions such as applying a heel floating device, off-loading the ulcer site, and repositioning every two hours, but these were not consistently implemented. Observations revealed that the resident's heels were often lying directly on the mattress without pressure relief or off-loading, and pressure-relieving boots were not applied as ordered. The resident reported that the heel boots were not being used, and a CNA confirmed that they had not attempted to turn the resident or apply the boots. The Assistant Director of Nursing and an LPN were unaware of the physician's orders for pressure-relieving boots, indicating a lack of communication and adherence to the care plan. The facility's policy on pressure ulcer prevention and treatment emphasizes the use of pressure-reducing devices for residents at risk. However, the staff failed to follow these guidelines, resulting in the resident's condition worsening. The wound nurse practitioner confirmed that the ulcer was caused by pressure and was facility-acquired, highlighting the facility's failure to provide adequate care and prevent the development of the pressure ulcer.
Failure to Obtain Physician-Ordered Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for a resident, identified as R2, by not obtaining a physician-ordered medication, Cyclobenzaprine Hydrochloride 10 mg, from the pharmacy. This deficiency was observed when a Licensed Practical Nurse (LPN) was administering scheduled medications and found that the medication was not available in the medication cart. The LPN acknowledged the issue and mentioned ongoing trouble with obtaining the medication from the pharmacy, without knowing the specific reason. Further investigation revealed that the resident missed six scheduled doses of the medication over two days. The LPN admitted to not notifying the resident's doctor about the unavailability of the medication. The Director of Nursing (DON) confirmed that the medication was not administered and stated that nurses should notify both the resident and the doctor immediately when a medication is unavailable. The facility's policy on unavailable medications outlines procedures for notifying the physician and obtaining alternative orders, which were not followed in this case.
Failure to Conduct Anti-Psychotic Medication Assessments and Gradual Dose Reductions
Penalty
Summary
The facility failed to perform necessary assessments and documentation for the use of anti-psychotic medication in a resident diagnosed with dementia. The resident, who was admitted to the facility without a mental illness, was prescribed Seroquel for dementia with psychotic disturbance. Despite receiving Seroquel regularly, there were no attempts at gradual dose reduction, nor was there any physician documentation explaining why such a reduction was clinically contraindicated. Additionally, the facility did not conduct any anti-psychotic medication assessments since the medication was initiated. Observations and interviews revealed that the resident had no documented behaviors that would justify the continued use of Seroquel. The resident expressed a desire to reduce medication due to feeling tired, and staff confirmed the absence of behaviors over the past six months. The facility's Director of Nursing acknowledged the lack of behavior tracking and gradual dose reduction attempts, which are required by the facility's psychotropic medication protocol.
Failure to Explain Arbitration Agreement
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand, and did not inform them that the agreement could be rescinded within 30 days of signing. This deficiency was identified through interviews and record reviews, revealing that the Social Services staff member responsible for admissions incorrectly informed residents and their representatives that they had 60 days to rescind the agreement and did not clarify that signing the agreement meant waiving their right to sue the facility. This oversight potentially affects all 59 residents in the facility. During a Resident Council Meeting, four residents expressed that they were unaware of the arbitration agreement and its implications, and did not know if they or their representatives had signed it. Additionally, a Power of Attorney for one resident stated that he did not understand the legal implications of the agreement and intended to rescind it. Another Power of Attorney confirmed signing the agreement without understanding its significance, indicating a lack of proper communication and understanding. The facility administrator acknowledged the absence of a policy regarding the arbitration agreement and emphasized the importance of residents and their representatives understanding its meaning.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pekin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timbercreek Rehab And Health Care Center | 1.3 mi | ★★★★★ | 10 | 1 |
| Pekin Manor | 1.5 mi | ★★★★★ | 4 | 0 |
| Arcadia Care Morton | 7.7 mi | ★★★★★ | 15 | 0 |
| Apostolic Christian Restmor | 8.7 mi | ★★★★★ | 1 | 0 |
| Fondulac Rehabilitation And Health Care Center | 9.3 mi | ★★★★★ | 4 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hallmark Healthcare Of Pekin.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.