Hallmark Healthcare of Pekin Resident Suffers Severe Medical Neglect Leading to ICU Hospitalization

The Illinois Department of Health has cited and fined Hallmark Healthcare of Pekin when staff failed to notify the resident’s physician about a significant decline in condition, resulting in two weeks with minimal medical treatment. The resident was eventually hospitalized in the ICU with severe dehydration, sepsis, kidney failure, and multiple other life-threatening conditions.

The resident in question, who had dementia and an indwelling urinary catheter, began showing signs of deterioration including refusing to eat, sleeping constantly, darker urine output, increased pain, and developing contractures in his lower legs that prevented him from straightening them.

Multiple staff members noticed these changes but failed to follow the facility’s own policies requiring immediate physician notification for acute changes in condition. A Certified Nursing Assistant observed that “Usually I could talk to the resident and the resident would talk back. The resident started sleeping all the time and wasn’t eating as much. I did notice the resident’s urine was darker than usual with a little less output.” A Licensed Practical Nurse acknowledged “I reported about the resident’s decline in condition. I did not notify the doctor however and should have.”

Instead of contacting the physician, staff focused on discussing hospice care with the family. The Social Services Director contacted family members about the resident’s decline but admitted “I did not call the resident’s physician regarding the resident’s condition and I am not aware if nursing notified the physician of the resident’s condition.” When the family member asked if the resident should be sent to the hospital, the Director of Nursing reportedly told them that the hospital would likely just send him back because there was nothing they could do.

The situation became critical when a Registered Nurse found the resident “lethargic with involuntary jerking, very slow to respond, increased weakness and fatigue noted, slow to respond and slurred speech, hypotension noted, Blood Pressure 66 systolic/44 diastolic.” At this point, the nurse sent the resident to the emergency room, later stating that “she could not take it anymore with the resident’s condition and that her conscience got the best of her.”

Upon arrival at the hospital, medical staff discovered shocking evidence of neglect. The admitting nurse described finding the resident’s “mouth and teeth were caked with black sludge that took me ten minutes and 12 different swabs to even try to get it out of his mouth” and noted “a lack of oral care like no one ever cleaned his mouth.” The resident’s catheter area was severely compromised, with the nurse observing that “The head of the resident’s penis, from the catheter rubbing and not cared for, was actually split.”

Hospital staff had to immediately replace the resident’s urinary catheter and discovered a massive blockage, with “immediate return of two liters (2,000 milliliters) of purulent appearing urine.” The hospital physician stated that “His creatine lab was 4.94 which indicates someone has been dehydrated for at least more than two days” and concluded that “the resident did not get like that in just one day. I felt the resident should have been hospitalized well before he was sent to us.”

The resident’s physician confirmed he had not been contacted about any decline, stating “I was not made aware of the resident’s declining condition. I last saw the resident on 4/8/25 and I do not have any record of the facility notifying me of the resident’s change in condition. I would have sent the resident right to the hospital and not messed with doing anything in house if the facility would have notified me of his condition.”

Medical records revealed the resident had lost nearly 14% of his body weight over six months, had not received ordered weekly weights, consumed only 25% or less of his meals for most of an eleven-day period, and showed no documentation that his urinary catheter had been changed since January. The facility’s own policies required staff to contact physicians immediately for acute changes in condition and to monitor residents with catheters for signs of infection.

The resident was diagnosed with 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. He required intensive care unit treatment and remained hospitalized at the time of the investigation. The facility was cited for an Immediate Jeopardy violation, the most serious level of deficiency in nursing home care.

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