Hallmark Healthcare Of Pekin
Inspection Findings
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions for one of three residents (Resident R1) reviewed for infection control in a sample of three. Findings Include:Resident R1's current Physician Order Sheet documents, Enhanced Barrier Precautions related to indwelling (urinary) drainage catheter.On 9/16/25 at 1:40pm, Resident R1 was in bed, with a urinary drainage bag hanging on
the lower aspect of his bed frame. Resident R1's urinary drainage bag contained approximately 400 milliliters of clear yellow urine. Resident 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 Resident R1. V4 then pushed Resident 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.
V4 stated that she only wears gloves while performing personal care, unless the resident is on contact or droplet isolation. V4 verified that she only had gloves and a mask on while performing Resident R1's personal care.
On 9/17/25 at 11:00am, V3, Assistant Director of Nursing/Licensed Practical Nurse, stated that signs are to be outside of the resident's room indicating the type of isolation the resident is on. V3 verified that any resident with an indwelling urinary catheter is to be on EBP. V3 also stated that there should be an isolation cart outside of the room. V3 verified that Resident R1 did not have an EBP sign on his door. The facility's Enhanced Barrier Precautions policy, revised 12/10/24, documents that EBP (Enhanced Barrier Precautions) are used
in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organisms) to staff hands and clothing. EHB are indicated for residents with any of the following has a wound or indwelling medical device and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO.
For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube or tracheostomy, ventilator. wound care: any skin opening requiring a dressing.
Residents Affected - Few
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
Event ID:
HALLMARK HEALTHCARE OF PEKIN in PEKIN, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PEKIN, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HALLMARK HEALTHCARE OF PEKIN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.