Health inspection·September 9, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm stated We are behind with care plan updates, our last care plan person has been gone for about three weeks, and we try to update the care plans quarterly (every three months) and as the need arises. I see (R27's) care plan has monthly weights but has nothing about his daily weights, bilateral tubigrips, Chronic Kidney Disease Stage 3 or Heart Failure diagnoses but we will add them. Residents Affected - Few 2. R54's medical record documents R54 has a left-hand contracture. On 09/06/22 at 10:20 AM R54 stated I'm supposed to have a carrot in my left hand to help prevent this (contracture), but they lost my carrot. It's been a few days since I've used it. They call it a carrot because it looks like a carrot. It's a soft pillow like device that fits into my hand and opens it up. The staff don't know where it's at. On 09/07/22 at 1:32 PM, V6, Certified Occupational Therapy Aide (COTA) stated We did the evaluation for (R54)'s left hand contracture. After the assessment, we started her on a trial to use a therapy carrot to see how she does with it. (R54) is doing really good with it because (R54) actually uses her carrot more than any other resident. The carrot helps prevent further contraction (Tightening) of the hand. She's supposed to have the carrot. I brought you (R54)'s Occupational Therapy (OT) evaluation and highlighted the section that address the need for interventions of her contracture. R54's Occupational Therapy (OT) evaluation dated 8/29/22 through 9/27/22 documents Clinical impression/Reason for skilled services: Patient would benefit from skilled OT interventions to provide continued assessment of orthotic and establish wear schedule with caregiver and patient education as needed as well as address underlying impairments that are impacting functional performance. R54's current care plan does not address R54's left-handed contraction or interventions for the left-hand contracture. On 9/9/22 at 8:57 AM, V2 Director of Nursing (DON) stated I looked at the (R54)'s care plan and her contracture wasn't added to it. We have a new Care Plan Coordinator that's still learning, so it was missed. It definitely should have been in there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 2 of 10 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 09/09/2022 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to update a care plan to include current pressure ulcers and interventions for one (R25) of 15 residents reviewed for care plan revision in a sample of 24. Findings include: Facility Care Planning policy, revised 7/14/22, documents To utilize the results of the comprehensive assessment to develop, revise, and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident. It is the responsibility of the staff to ensure that when providing care, the care plan information is utilized. Concerns and problems sources are, but not limited to relating to diagnoses, physician's orders, and problems related to preventive care. Approach/Plan: List care to be provided for the problem listed. The care must be necessary and appropriate to accomplish the goal stated. Individualized care for the unique needs of the resident. List preventive measures. Re-evaluation date: All care plans must/shall be updated at least quarterly and as needed. Update the Resident Care Plan: Update the resident care plan on problems according to facility policy, as need arises. Resident Care Plan Documentation and Use of the Plan: The MDS/Minimum Data Set nurse shall evaluate every new order form the physician to determine if the resident's care plan requires updating, and the resident care plan must be kept current. R25's physician order sheet, dated September 1-30th 2022, documents the following: Heel protectors on at all times except during cares four times a day, Med Pass 2.0 three times a day for weight loss give 90mL/milliliters may substitute health shake if not available, and 30cc/cubic centimeters prostat TID/three times a day for wound healing. Wound of the right lateral foot-cleanse with wound cleanser and apply xeroform and cover with a bordered gauze dressing change every three days and PRN/as needed every night shift. Wound of the right hip-cleanse with wound cleanser apply silver alginate and cover with a bordered foam dressing change daily and PRN every night shift for wound. Wound of the left lateral buttock-cleanse with wound cleanser and apply silver alginate and cover with a dry dressing change daily and PRN every night shift for wound. Wound of the left anterior knee-cleanse with wound cleanser apply xeroform and cover with a bordered gauze dressing change every three days and PRN every night shift for wound. Wound of the left hip-cleanse with wound cleanser apply silver alginate and cover with a bordered foam dressing change daily and PRN every night shift for wound. On 9/07/22 at 12:50 PM, R25 was in bed with bilateral heel protectors on. R25's right foot, right hip, left buttock, left knee, and left hip dressings were intact. R25's current care plan does not have all of R25's current pressure ulcers indicated on the care plan and does not include R25's current skin/wound healing orders including bilateral heel protectors, prostat for wound healing, and med pass for weight loss. On 9/08/22 at 11:50 AM, V2 DON/Director of Nursing stated, Our last Care plan/MDS-Minimum Data Set person quit in July (2022), so we are covering as best we can, we hired our current Care plan/MDS person about two weeks ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 3 of 10 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 09/09/2022 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm On 9/08/22 at 11:54 AM, V5 ADON/Assistant Director of Nursing and prior care plan coordinator/MDS stated We are behind with care plan updates, our last care plan person has been gone for about three weeks, and we try to update the care plans quarterly (every three months) and as the need arises. V5 verified all of R25's pressure ulcers, prostat, med pass supplement, and bilateral heel protectors were not on R25's care plan and should be since they are part of her individualized care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 4 of 10 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 09/09/2022 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to document circumstances requiring a discharge to the hospital and monitoring upon readmission for one resident (R14) of 3 residents reviewed for change of condition in a total sample of 24. Residents Affected - Few Findings Include: The Facility's admission Procedure policy dated 5/17/22 documents It is the responsibility of all staff to ensure the needs of a new admission into the facility are met and the documentation is in place addressing the interventions utilized with in the time frame defined by CMS (Center for Medicaid and Medicare Services). The Facility's admission Procedure Policy documents When a resident is admitted to the nursing unit the admitting nurse must document the following information in the nurses' notes, admission form, or other appropriate place as designated by the facility. a) The date and the time of the resident's admission, b) The resident's age, sex, race and marital status, c) From where the resident was admitted (i.e., hospital, home, other facility) d) reason for the admission, e) The admitting diagnosis, f) The general condition of the resident upon admission, g) The time the Attending Physician was notified of the resident's admission, h) The presence of a catheter, dressings, etc., i) A brief description of any disabilities (i.e., blind, deaf, hemiplegia, speech impairment paralysis, mobility, etc.), j) Any known allergies, k) Prosthesis required (i.e., glasses, dentures, hearing aid, artificial limbs, eye, etc.), l) The height and weight of the resident, m) Initiate the initial care plan, n) The signature and title of the person recording the data. R14's Medical Record documents R14 was discharged to the hospital on 7/21/22. R14's Nurse's Notes do not include any documentation of an assessment or reasoning regarding why R14 went to the hospital. R14's Hospital Discharge Record dated 7/24/22 documents You were treated for Metabolic Encephalopathy. R14's Medical Record documents that she returned to the facility on 7/24/22. R14's record does not include why R14 was hospitalized and does not include any monitoring or assessments of R14 regarding R14's Metabolic Encephalopathy. On 9/7/22 at 9:00 AM V1 (Administrator) confirmed there was no documentation regarding R14's recent hospitalization and stated Why (R14) went to the hospital should definitely be charted, and the nurses should have been monitoring her since she came back. On 9/8/22 at 1:00 PM V2 (Director of Nursing) confirmed there was no documentation regarding R14's recent hospitalization. V2 also confirmed there has been no monitoring of R14's condition since she returned from the hospital on 7/24/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 5 of 10 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 09/09/2022 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review, the facility failed to follow occupational therapy's treatment plan to utilize an orthotic device to help prevent further contraction of the left hand for one resident (R54) of three residents reviewed for range of motion out of a sample of Findings Include: The facility's Restorative Program/Range of Motion policy revised 2/3/22 documents Purpose: To provide residents with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. R54's medical record documents R54 has a left-hand contracture. On 09/06/22 at 10:20 AM, observation of R54's left hand contracture. Resident can slightly open left hand. Upon R54 opening her left hand, it's observed that there's no device preventing R54's fingernails from coming in contact with her palm or to prevent further contracture. R54 stated I'm supposed to have a carrot in my left hand to help prevent this, but they lost my carrot. It's been a few days since I've used it. They call it a carrot because it looks like a carrot. It's a soft pillow like device that fits into my hand and opens it up. The staff don't know where it's at. On 09/07/22 at 1:13 PM, R54 observed lying in bed with napkin rolled up in her left hand. R54 stated I put the napkin in my hand because my fingernails are digging into my hand and it's starting to hurt. They still don't have my carrot. I keep asking for it, but they still can't find it. On 09/07/22 at 01:32 PM, V6, Certified Occupational Therapy Aide (COTA) stated We did the evaluation for (R54)'s left hand contracture. After the assessment, we started her on a trial to use a therapy carrot to see how she does with it. (R54) is doing really good with it because actually uses her carrot more than any other resident. The carrot helps prevent further contraction (Tightening) of the hand and it also helps prevent her fingernails from digging into her hand. When I went in to see her yesterday, (R54) had a washcloth in her hand because the staff couldn't find her carrot. We usually have a box of carrots in therapy. If they lose it, the staff can come down and ask for a new one so I'm not sure why she went without one. I brought you (R54)'s Occupational Therapy (OT) evaluation and highlighted the section that address the need for interventions of her contracture. R54's Occupational Therapy (OT) evaluation dated 8/29/22 through 9/27/22 documents Clinical impression/Reason for skilled services: Patient would benefit from skilled OT interventions to provide continued assessment of orthotic and establish wear schedule with caregiver and patient education as needed as well as address underlying impairments that are impacting functional performance. On 9/8/22 at 2:00 PM, V2, Director of Nursing (DON) stated (R54) shouldn't have gone without a carrot. If there's a box of them in therapy, then someone should have gone down and got her a new one. She should have had it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 6 of 10 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 09/09/2022 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to hang oxygen (O2) in use signage, document O2 titration, tubing and humidification bottle changes and failed to date O2 tubing for one (R155) of one resident reviewed for oxygen therapy in a sample of 15. Residents Affected - Few Findings include: Facility Oxygen Administration Policy, revised 3/17/22, documents: to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; oxygen therapy will be administered to the resident upon the written order of a licensed physician; it is the responsibility of the Charge Nurse to ensure that residents, who have an order for oxygen or will be obtaining an order for oxygen are receiving the proper amount via the proper way; required equipment includes a No Smoking/Oxygen in Use sign; check the order and place the oxygen in use sign on the outside of the room entrance door; observe the resident to be sure oxygen is being tolerated; prefilled disposable humidifiers will be changed when necessary; and label humidifier with date opened and tubing will be changed and dated weekly. R155's Physician Order Sheet, dated 9/7/22, documents R155's diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Dependence of Supplemental Oxygen; and a physician's order for oxygen at two liters per nasal canula (2LNC) continuous. R155's Medication and Treatment Administration Records, dated 8/22/22 through 9/6/22, does not document O2 titration use or changing of tubing/humidification bottle change. On 9/6/22 (8:55 AM, 9:43 AM and 1:12 PM) and 9/7/22 (8:41 AM, 11:36 AM and 12:10 PM), R155's oxygen was on and titrated at two liters per nasal canula (2LNC) via a room concentrator. There is no date on the oxygen tubing and no oxygen in use sign was on the door. On 9/8/22, at 2:48 PM, V5 (Assistant Director of Nursing/DON) verified that R155's oxygen tubing was not dated. On 9/7/22, at 11:42 AM, V2 (Assistant Director of Nursing/DON) stated, I do not see, on the Medication Administration or Treatment Administration Records, that we are changing and documenting the tubing and humidification bottle for (R155). I will get that added to the Medication Administration and Treatment Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 7 of 10 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 09/09/2022 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview, the facility failed to identify and document specific behaviors necessitating the need for psychotropic medications for one resident (R41) of three residents reviewed for psychotropic medications in a total sample of 24. Findings Include: The Facility's Psychotropic Medications Policy dated 5/26/2022 documents In accordance with federal and state regulations, it is this facility's policy that residents will not be given unnecessary medications. The Facility's Psychotropic Medications Policy documents A behavior tracking record is used to keep record of resident's behaviors as required by federal regulations. The care plan will include objectives for gradual dose reduction as well as alternative interventions to assist in gradual dose reduction in accordance with Federal Regulations. R41's Physician Order Sheet for September 2022 documents R41's psychotropic medications as: Zolpidem 10 mg (milligrams) every night, Duloxetine 30 mg every day for Depression, Sertraline Hydrochloride 100 mg every day for Depression, Lorazepam 0.5 mg twice daily for Anxiety, Hydroxyzine 25 mg three times a day for Anxiety, Hydroxyzine 25 mg every 12 hours as needed for Anxiety. R41's Behavior Monitoring lists frequent crying, repeats movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care, and none of the above observed. On 9/7/22 at 1:12 PM V7 (Social Services Director) confirmed that the behavior monitoring form for R41 is a generic form with most possible behaviors listed for staff to choose from. V7 stated We do put specific behaviors on the behavior monitoring forms if we know them. I cannot think of any behaviors for (R41) that she has ever displayed in my 2 years of working with her. V7 could not explain why R41 would be on two medications for depression, two medications for anxiety and a medication for Insomnia. I am not aware of any issues with (R41). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 8 of 10 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 09/09/2022 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)

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 maintain transmission-based precautions for two residents (R31, R41) of five residents reviewed for infection control in a total sample of 24. Residents Affected - Few Findings include: The facility's Isolation for Transmission Based Precautions policy revised 6/20/22 documents Contact Precautions: 4. Staff will wear gloves (clean, non-sterile) when entering the room. 5. Staff and visitors will wear disposable gown upon entering the room and remove before leaving the room and will avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions: 4. Gloves, gown, and goggles should be worn if there is a risk of spraying respiratory secretions. The facility's Personal Protective Equipment (PPE) policy dated 5/31/22 documents 5. Provide the right supplies to ensure easy and correct use of PPE. a. Post signs on the door or wall outside of the resident's room to advise staff to take precautions. Signage on affected rooms will include the type of precautions to be utilized and instructions to use specific appropriate PPE. b. The facility will utilize Transmission Based Precautions appropriate to the circumstances as defined by the CDC (Center for Disease Control) to assure the selection of PPE. The CDC's (Center for Disease Control and Prevention) Prevent the Spread of C. diff guidelines dated 7/20/21 documents C. diff germs are carried from person to person in the feces. If someone with C. diff (or caring for someone with C. diff) doesn't clean their hands with soap and water after using the bathroom, they can spread the germs to people and things they touch. C. diff can also live on people's skin for months. People who touch an infected person's skin can pick up the germs on their hands. Alcohol based hand sanitizers are ineffective in killing c. diff due to the spores. Washing with soap and water is the best way to prevent the spread from person to person. 1. R41's current physician order dated 8/11/22 documents Droplet Isolation precautions for MRSA (Methicillin-resistant Staphylococcus aureus) of the Sputum. On 09/07/22 at 9:14 AM, V3, Licensed Practical Nurse (LPN), observed entering R41's room with N95 mask and face shield on. There is a sign posted at the entryway of R41's room identifying R41 as being under droplet isolation precautions. V3, LPN entered the room and did not don additional PPE, walked across the room to the window where R41 was sitting and gave R41 a medication cup with medication in it and a cup of water. R41 poured the medications directly into her mouth from the medication cup, drank the water from the cup and then handed the medication cup and water cup back to V3, LPN. V3, LPN threw them in the garbage and exited the room. After exiting the room, V3, LPN sanitized her hands and stated I don't know why (R41) is on isolation precautions. I can look it up. It looks like she's on droplet isolation for MRSA of the sputum. V3, LPN, looked behind her at the isolation cart outside of R41's room and acknowledged she should have worn droplet precaution level PPE when entering R41's room. 2. R31's current physician order dated 8/3/22 documents Isolation for C. Diff (Clostridium Difficile). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 9 of 10 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 09/09/2022 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/07/22 at 9:27 AM, V4, Medical Records (MR), was observed entering R31's room with only a N95 and face shield on. There was a sign posted at the entryway of R31's room identifying R31 as being under contact isolation precautions. V4, MR, was observed touching R31 with ungloved hand, speaking with R31 and then exiting the room. After exiting the room, V4, MR, used hand sanitizer and stated I don't know why (R31) is under contact precautions. I didn't notice it when I went in. I was just walking by, saw the call light on, so I went in to see what she needed. I should have worn the gown and gloves when entering the room. On 9/8/22 at 2:00 PM, V1, Administrator and V2, Director of Nursing (DON) and V6, Assistant Director of Nursing (ADON) verified R31 and R41 are under transmission-based precautions and stated V3, LPN-Licensed Practical Nurse, and V4 MR, should have worn the identified level of PPE-Personal Protective Equipment when entering R31 and R41's room. V2, DON, stated V4, MR, should have washed her hands with soap and water instead of using the hand sanitizer due to (R31) having C. Diff. On 9/9/22 at 11:00 AM, V2, Director of Nursing (DON), stated We don't have a policy that addresses C. diff. We just use the CDC-Centers for Disease Control and Prevention standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 10 of 10