Health inspection·August 24, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to ensure a resident's bathroom was clean for two of 24 residents (R10, R26) reviewed for a clean, homelike environment in a sample of 24. Residents Affected - Few Findings include: A Deep Clean Procedures policy (undated) states, Starting in a clockwise rotation from the resident room door: clean, polish, scrub, scrape, dust, disinfect, sweep, wipe, and mop everything in the room, including dust mop and damp mop the entire room, and check all corners, ceiling and floor for cobwebs. A grievance log dated 7/31/23 documents that R10 complained to the facility about cleanliness. On 8/22/23 at 1:09 pm, R10 stated he had concerns with the cleanliness of the floor in his bathroom. R10 stated there is a build-up of dirt and grime at the baseboards and in the corners, and it has been that way for a while now. R10 stated he is going to have his family member clean it for him, because it wasn't getting taken care of by the facility. On 8/23/23 at 11:00a.m. R10 was in his room seated in a wheelchair. R10 stated he shares his room with R26. R10 stated his bathroom was not being properly cleaned stating that a visitor commented to him on the soiled condition of his bathroom. Upon inspection of R10's bathroom at that time there was black crumbly debris on the floor between the toilet and the wall. The corners of R10 and R26's bathroom, near the floor, had cobwebs and a spider in a spider web. The floor in front of their shower had soiled pieces of paper and a small adhesive dressing was sticking out from under the bathmat. R10 stated he had complained to the facility that his bathroom was not being swept properly a few weeks ago but it is still not being properly swept clean. On 8/23/23 at 11:33a.m. V19 (Housekeeper) stated that she cleans residents' rooms and bathrooms every day. V19 stated she hadn't cleaned R10 and R26's room yet but was going to be heading to their room shortly. On 8/24/23 at 10:00a.m. R10 and R26's bathroom still had the debris on the floor between the toilet and the wall, the soiled paper and adhesive dressing under the bathmat was still present. There was dirt along R10's baseboard, and cobwebs with a spider was still in the corners of the bathroom. R10 stated that V19 had cleaned R10's room and bathroom the day before, however, R10 stated, his bathroom is still not very clean. R10 demonstrated that he now had a dustpan and stated that as soon as his family brings him a broom, he will try to clean the bathroom himself. On 8/24/23 at 2:39p.m. V1 (Administrator) stated that housekeepers are supposed to clean residents' rooms and bathrooms every day. V1 stated in response to R10's concerns about the cleanliness of his room, bathroom, and the facility, (R10's) particular. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 2 of 18 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 08/24/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide supervision to a cognitively impaired resident with a history of falling, for one of one resident reviewed (R55) for falls with major injury and failed to ensure a wandering resident did not enter other residents rooms for one of one resident (R29) in a sample of 56. This failure resulted in R55 falling from her wheelchair as she was unsupervised, on 8/06/23 and sustaining a left hip fracture. Findings include: 1. On 8/21/23 at 11:54 am, R55 was sitting in a high back reclining wheelchair with a lap tray. R55 was non-verbal and leaning forward with her head resting on the lap tray. On 8/22/23 at 10:23 am, R55 was sleeping in bed with a staff member sitting in the doorway providing 1:1 supervision. The Electronic Record Face Sheet documents R55 was admitted to the facility on [DATE] with the diagnoses of Non-displaced Fracture of the Second Cervical Vertebra with Subsequent Encounter for Fracture with Routine Healing, Aftercare Following Surgery on the Nervous System, Encephalopathy, History of Falling and Major Depressive Disorder. A Fall Risk Assessment completed 6/16/23 determined R55 to be high risk for falls. Nursing Notes, dated 6/17/23, document R55 was transferred to the local Hospital for chest pain, was admitted for Pneumonia, Urinary Tract Infection and Acute Metabolic Encephalopathy and did not return to the facility until 7/10/23. R55's 7/10/23 Hospital Transfer/readmission documentation indicates R55 was started on Seroquel (Anti-psychotic) 25 mg (milligrams) daily during that hospitalization and orders were given for R55 to continue the Seroquel 25 mg daily. A repeat Fall Risk Assessment on 7/10/23 documents R55 continued to be high risk for falling. R55's Plan of Care, which was revised on 7/13/23 documents (R55) is at risk for falls and injuries (related to) a (history) of falls prior to admission, use of narcotics for pain control, poor safety awareness secondary to (a diagnosis) of Dementia, daily use of Psychotropic medication, daily use of Antipsychotic medication and age. (R55) gets agitated when staff try to redirect her. Nursing Progress Notes document R55 fell a total of eight times between 7/14/23 and 8/03/23. Physician's Orders document R55's Anti-psychotic medication, Seroquel was doubled in dose to 25 mg twice per day (on 7/19/23), an additional Anti-psychotic, Zyprexa 2.5 mg daily was added on 7/28/23. Physician's orders document R55's Seroquel was doubled again on 7/29/23, to 50 mg twice per day. Manufacture's Prescribing Information cites patients on Seroquel are at an increased risk of sedation, somnolence and dizziness, which could lead to falling. Fall Investigations indicate R55 experienced her first fall at the facility on 7/14/23, when R55 was witnessed by staff to stand from her wheelchair, land on her buttocks when she went to sit down, sustaining no injury. The next Fall Investigation, dated 7/15/23, documents R55 was observed by staff to stand from the dining room table, lose her balance and fall to the ground, without injury. The 7/15/23 Fall Investigation determined R55 was barefoot when she fell and needed to always have proper footwear on. A Fall Investigation, dated 7/17/23, documented R55 experienced an unwitnessed fall and was found, uninjured, by staff sitting on the floor in front of her wheelchair in the dining room. Documentation indicates the facility put a Dycem (non-slip pad) in the seat and added an anti-roll back devices to R55's wheelchair. A 7/18/23 Fall Investigation documented R55 was found lying on her side in the hallway and the fall was unwitnessed. The 7/18/23 Fall Investigation determined R55 was uninjured and had likely wandered into the hallway looking for a bathroom, so a nightlight was placed in R55's room and she was to be encouraged to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 3 of 18 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 08/24/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few toilet prior to bedtime. Another Fall Investigation, dated 7/23/23, documents staff observed R55 stand from her wheelchair and then kneel onto the floor before staff could assist her. The 7/23/23 Fall Investigation determined R55 was restless in the dining room, stood independently and was uninjured, with instructions for staff to offer R55 to lay down in bed between meals. A Fall Investigation, dated 7/30/23, documents staff observed R55 standing next to her wheelchair, turn and fall onto her right side, sustaining a skin tear to her right wrist and a bump to the left side of her head. The 7/30/23 Fall Investigation determined Resident has Dementia and is confused. Attempted to stand from chair without assistance, with an intervention of a pressure alarm to be placed in R55's wheelchair. Another Fall Investigation, dated 8/02/23, documents staff observed R55 get up out of her wheelchair and fall to the floor, without sustaining an injury. The 8/02/23 Fall Investigation determined R55 attempted to stand unassisted and lost her balance, with an intervention of Supervision will be increased by way of sitting at the nurse's station and management offices with staff and engaging in meaningful conversation. A Fall Investigation, dated 8/03/23, documents staff witnessed R55 standing in the hallway with her wheelchair behind her as she fell backwards onto her buttocks. The 8/03/23 Fall Investigation concluded that R55 was uninjured, has poor safety awareness due to Dementia and recommended applying a soft lap restraint to keep (R55) safe from falls. Lastly, a Fall Investigation, dated 8/06/23 at 11:20 am, documents, This nurse was notified by (resident's Certified Nursing Assistant) that this resident had a fall out in the hallway. This nurse witnessed resident on the ground next to wheelchair with (Certified Nursing Assistant) and staff present at the scene. (R55) unable to state what happen(ed) and if she is experiencing any pain. (R55) unable to give description. Vitals (within normal limits). No injuries noted. (R55) unable to state any pain. No visible sign of trauma noted. Skin intact. Oriented to self. (R55) is now being (placed) on 1:1 supervision by staff. Nursing Notes from 8/06/23 document R55 had displayed signs of discomfort during transfer to bed at 9:00 pm, and at Around (11:00 pm) CNA (Certified Nursing Assistant) told nurse (R55) continued to display signs of pain during bed check. Resident held her left hip while lying down while grimacing, so nurse called to have resident sent to (local Hospital) to have her hip (x-rayed). Hospital Records, dated 8/07/23, document R55 was found to have an acute, displaced, overriding subcapital left femoral neck fracture with overriding at the fracture site. The Hospitalist Discharge summary, dated [DATE], documents Family opted against surgery (of femoral neck fracture) and instead wanted her moved to palliative/comfort care, had agitation related to Dementia, being in new setting, etc. An Administrative Summary/Verification of Incident Investigation dated 8/06/23, documents (R55) had a fall in the hallway out of her wheelchair, not witnessed. Resident was unable to state what she was doing, due to her cognitive status. She was likely attempting to get out of (her) wheelchair to ambulate unassisted. The nurse immediately assessed resident, and vital signs (were) completed. (R55) had no noted abnormalities, edema, redness, and no open areas, so she was assisted back to (her) wheelchair per staff. (R55) continued with 1 on 1 supervision by (Certified Nursing Assistant). (R55) was being transferred to bed by staff later that night and she was noted to show signs of discomfort. The nurse completed assessment and sent resident to Hospital for an evaluation related to her signs and symptoms of pain during weight bearing activities. (R55) was diagnosed with a left hip fracture and returned to the facility. A witness statement, from V18 (Certified Nursing Assistant), dated 8/07/23, documents I don't remember exactly what time I actually toileted the resident that day, but when I take care of her, I normally attempt to take her to the bathroom every hour or hour and a half. That day, I went to break and let the nurse know I was leaving the unit. When I came back on the unit, I saw (R55) laying in the hallway. I was gone approximately 15 minutes. (R55) was a couple feet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 4 of 18 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 08/24/2023 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 0689 from her wheelchair, so it appeared she may have tried to ambulate without assistance. I immediately went and got the nurse. Level of Harm - Actual harm Residents Affected - Few On 8/24/23 at 11:40 am, V2 (Director of Nursing) stated R55 had repeatedly fallen because she would stand from her chair and try to ambulate independently. V2 stated R55 could only ambulate with a gait belt and standby assistance of staff. V2 stated they tried using a soft lap restraint in R55's wheelchair to remind her she shouldn't stand independently, but R55 would just pull it off the wheelchair and throw it. V2 stated they tried using a pressure alarm in the seat of R55's wheelchair, but that agitated R55, and she would turn it off. V2 indicated, this was when they decided R55 should be at the Nurse's Station for increased supervision by staff when up in her wheelchair. V2 stated she would expect staff to have R55 within arm's reach, not just visual supervision. V2 stated her investigation into the 8/06/23 fall concluded that R55 was in the hallway by the Social Service office, and not at the Nurse's Station when she fell. According to V2, based on the location of where R55 was found on the floor and the location of her wheelchair, it appeared R55 had stood from her chair and taken a couple of steps and then fell. V2 stated, even if R55 had been left at the Nurse's Station, she needed to be monitored because she would propel away, so, someone had to watch her. V2 confirmed that V18 had left the unit for break at the time of R55 fall and there was no staff around to witness the incident. On 8/24/23 at 1:19 pm, V10 (Licensed Practical Nurse) stated she was R55's nurse on 8/06/23. V10 stated she gave R55 her medication around 11:00 am, and at that time R55 was sitting in her wheelchair in the hallway near the Social Service office. V10 didn't recall any additional staff in the area at that time. V10 then took her medication cart into the dining room to finish her medication pass. V10 indicated, several minutes later, she heard V18 (Certified Nursing Assistant) say R55 was on the floor. V10 stated she assessed R55 for injury and R55 did not express any verbal or non-verbal indicators of pain, so they assisted R55 back into her wheelchair. V10 stated she then took R55 into the dining room with her so she could monitor her more closely. V10 stated staff are to watch R55 closely, because she needs constant supervision, she likes to get up (on her own). V10 stated she was unaware that V18 had been out on break when R55 fell and indicated if she had known, she would have brought her (R55) with me on my med (medication) pass. V10 stated she was unaware that R55 had been care planned to be at the Nurse's Station for increased supervision, as well. 2. A Wandering/Elopement Policy dated 10/18/22 states, If identifies as at risk for wandering or elopement; the resident's care plan will include strategies and interventions that shall (be) implemented to maintain the resident's safety, including but not limited, to electronic monitoring device, room placement, frequent checks, etc. R29's Minimum Data Set assessment dated [DATE] documents R30 is severely cognitively impaired and requires supervision for locomotion on and off the unit and utilizes a wheelchair for mobility. R29's care plan dated 5/23/22 documents R29 is an elopement risk. This care plan instructs staff to, Provide re-direction and Diversion as needed. An additional intervention on R29's care plan dated 1/27/21 instructs staff to, keep within staff supervision when out of room. On 8/21/23 at 1:30p.m. while R10 was seated in a wheelchair in his room talking to visitors and with the privacy curtain closed, R29 self-propelled her wheelchair into R10's room around the privacy curtain and began to speak aggressively to R10 and the visitors. R29 seemed confused, disoriented, and was mumbling nonsensically but aggressively. V14 (Certified Nurse Aide) could be seen in the hallway walking towards R10's room. When V14 was just outside R10's room, V14 saw that R29 was in R10's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 5 of 18 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 08/24/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few room near R10 and R10's visitors, V14 shrugged her shoulders and turned to walk away. One of R10's visitors called out for V14 to come remove R29 from R10's room. V14 stated she did not know R29's name but that V14 knew which room belonged to R29 which was at the other end of the hallway. Once V14 had escorted R29 out of R10's room, R10 stated that R29 frequently wanders into his room without being invited. R10 stated he realizes R29 is confused and wanders, however, R10 stated he does not want R29 to wander into his room without permission. R10 stated that earlier that morning R29 wandered into his room while he was, On the pot, which made R10 uncomfortable. On 8/24/23 at approximately 2:39p.m. V1 (Administrator) was discussing R10's concerns including his concern with R29 wandering into R10's room and invading R10's privacy. V1 stated, V10's particular. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 6 of 18 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 08/24/2023 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 ensure oxygen tubing and nebulizer tubing was dated and stored in a bag between uses for one of one resident (R40) reviewed for respiratory care in a sample of 24. Residents Affected - Few Findings include: An Oxygen Administration policy dated 3/17/22 states, When Oxygen cannula/Mask is not in use it should be stored in a (plastic) or like bag attached to the oxygen concentrator. An Oral Inhalation Administration policy dated 9/2018 states, When equipment is completely dry, store in a plastic bag marked with the resident's name and the date. On 8/22/23 at 9:01a.m. R40 was lying in bed resting. R40's oxygen concentrator was located at the head of the bed between the bed and the window. R40's oxygen tubing was rolled up, laying on top of the concentrator and was undated and not placed in a plastic bag. R40's nebulizer machine was laying on R40's recliner with the tubing and mouthpiece laying on the linens in the recliner without being dated or placed in a plastic bag. On 8/22/23 at 9:09a.m. V13 (Licensed Practical Nurse) was preparing to administer R40's nebulizer treatment. V13 entered R40's room and verified R40's oxygen tubing, nebulizer tubing and mouthpiece were not dated and not placed in plastic bags stating, Normally it would be dated in a plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 7 of 18 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 08/24/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to identify target behaviors, document consistent adverse behaviors, attempt a gradual dose reduction, provide justification for duplicative therapy and justification for a dosage increase to warrant the continued use of an antipsychotic medication for three of four residents (R16, R30 and R55) reviewed for antipsychotic medications in the sample of 56. Findings include: The facility policy, titled Psychotropic Medications Policy Chemical Restraints (revised 5/25/23) documents Purpose: To provide guidelines to ensure that residents who receive antipsychotic/psychoactive medications are maintained at the safest and lowest dosage necessary to control the resident's condition. Policy: In accordance with federal and state regulations, it is this facility's policy that residents will not be given unnecessary medications. Psychotropic/Psychoactive medication will not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative. Additional informed consent is not required for reductions in dosage levels or deletion of a specific medication. The informed consent may provide for a medication administration program of sequentially increased dosages or combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome. The informed consent will be inclusive of common side effects of the medications to be administered. Residents shall only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. Residents who receive antipsychotic/psychoactive medications shall have gradual dose reductions attempted in accordance with state and federal regulation and behavior interventions reviewed, unless clinically contraindicated. Responsibility: It is the responsibility of the Charge Nurse/Physician, monitored by the Director of Nursing (or designee) and the Pharmacy Consultant to administer, prescribe and monitor antipsychotic medications administration. Procedure: 1. When an antipsychotic/psychoactive medication is selected for use, the specific clinical diagnosis for which the drug is being given must be in the resident record. 2. The resident, resident's guardian, or authorized representative will be provided with and have signed an Informed Consent for Psychotropic Medications. Psychotropic medications shall be used only after alternative methods have been tried unsuccessfully and only upon the written order of a physician and after informed consent had been obtained from the resident representative. 3. The resident/representative will be given information regarding the need for, the desired effects and the potential side effects of the medication. This enables the resident/representative to make an informed decision regarding the use of the medication. The family or resident will be included in the care planning process. 4. Chemical restraints will not be used to limit or control resident behavior for the convenience of staff. 5. A behavior tracking record is to be used to keep record of resident behaviors as required by federal regulations. 6. Each resident taking antipsychotic/psychoactive medications shall have their medications reviewed and documented by a physician 2 times per year, monthly by the Pharmacy Consultant, and quarterly or as needed by the Interdisciplinary Team. 7. Residents who use antipsychotic, antianxiety, or sedative/hypnotic medications will be reviewed as appropriate for gradual dose reduction, as per federal and state regulations, unless the physician documents in the medical record the need to maintain the resident's regimen. 8. Residents receiving psychotropic/psychoactive medications are to be monitored for the onset/presence of side effects by the appropriate Charge Nurse. Onset of side effects, and/or any change in the presence of side effects is to be documented in the medical record and the physician shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 8 of 18 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 08/24/2023 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 be notified. 9. All residents who receive antipsychotic medications will have an AIMS assessment completed every 6 months and as needed. 10. Residents receiving antipsychotic drugs will be maintained on the lowest dosage possible. 1. On 8/21/23 at 11:54 am, R55 was sitting in a high back reclining wheelchair with a lap tray. R55 was non-verbal and leaning forward with her head resting on the lap tray During lunch that day, the staff had to physically hold R55's head in an upright position to try to get her to eat. On 8/22/23 at 10:23 am, R55 was sleeping in bed with a staff member sitting in the doorway providing 1:1 supervision. R55 was unable to engage in any meaningful conversation at that time and was non-verbal. The Electronic Record Face Sheet documents R55 was admitted to the facility on [DATE] with the diagnoses of Non-displaced Fracture of the Second Cervical Vertebra with Subsequent Encounter for Fracture with Routine Healing, Aftercare Following Surgery on the Nervous System, Encephalopathy, History of Falling and Major Depressive Disorder. Nursing Notes, dated 6/17/23, document R55 was transferred to the local Hospital for chest pain, was admitted for Pneumonia, Urinary Tract Infection and Acute Metabolic Encephalopathy and did not return to the facility until 7/10/23. R55's 7/10/23 Hospital Transfer/readmission documentation indicates R55 was started on Seroquel (Anti-psychotic) 25 mg (milligrams) daily during that hospitalization and orders were given for R55 to continue the Seroquel 25 mg daily for the diagnosis of Behaviors. On 7/14/23, Nursing Notes document R55 was transferred to the local Hospital for altered mental status, behavioral symptoms (e.g., agitation, psychosis). 7/14/23 Nursing Notes detail R55 as kicking, hitting and pinching staff, taking a push pin from a cork board and attempting to stab a CNA (Certified Nursing Assistant) with it, flipping a table and chair, attempting to leave the building and throw herself onto the floor. Nursing Notes on 7/14/23 document R55 was returned to the facility three hours later after receiving a onetime does of Zyprexa (antipsychotic) intramuscularly and no additional new orders. Nursing Notes document on 7/18/23, R55 was transferred to the local Hospital again for chest pain and R55 had sustained a fall. On 7/19/23, R55 was returned to the facility with no new orders, according to Nursing Notes. Later on 7/19/23, Physician's Orders document that the facility's Nurse Practitioner increased R55's Seroquel to 25 mg twice per day for the diagnosis of Behaviors. The Nurse Practitioner's Progress Note, from 7/19/23, documents Patient seen today for follow-up since admission to SNF (Skilled Nursing Facility) and follow-up regarding dementia related behavior concerns. Patient is at SNF for (therapy) post C1-C2 Spinal fusion with open repair of fracture on 6/10/23. Patient has had 3 (emergency room) visits since this injury and admission to SNF. She was treated and returned to SNF. Patient seen today seated in wheelchair at time of assessment with hard c-collar in place. She continues to be notably confused, consistent with previous documentation. She is alert and oriented x 1. Review of systems attempted; however nonsensical cervical speech noted. She does not appear to be in pain or discomfort. She is currently being treated for pneumonia through 7/21/23. Review of systems attempted, however unreliable due to confusion. Patient states prior to recent surgery she lived at home with her husband. She denies any sores or wounds to her skin. Her c-collar appears to be ill fitting. Nursing staff report patient was given a new c-collar at recent (emergency room) visit. This appears to be too large for her. C-collar is up under her nose and over her mouth. Nursing staff have repeatedly adjusted it and it does not stay in place appropriately. Recommend Nursing staff reach out to orthopedics for any further recommendations regarding c-collar. Patient has multiple notations of continued dementia related behaviors, violent behavior to other residents and staff noted 7/14/23. She was recently started on Seroquel at bedtime, will recommend we increase Seroquel to 25 mg (by mouth) twice daily. However, R55's Behavior Tracking and Nursing Notes, from 7/15/23 to 7/19/23, document no further physical behaviors from R55 after 7/14/23, only a fall from her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 9 of 18 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 08/24/2023 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 wheelchair on 7/15/23 and refusal to wear her neck brace on 7/16/23. Level of Harm - Minimal harm or potential for actual harm On 7/28/23, the Physician's Orders document R55 was to receive a onetime dose of Zyprexa (antipsychotic) 5 mg for Dementia with Behavioral Disturbances, and then was to start Zyprexa 2.5 mg daily for combativeness and increase Seroquel to 50 mg twice per day (which was doubling the dose). R55's Behavior tracking from 7/19/23 to 7/28/23 and Nursing Notes document no behaviors other than R55 wandering on 7/27/23. On 7/29/23, Nursing Notes document, (R55) continues to get up from (wheelchair). Resident combative with staff during cares, resident reapproached and is cooperative and (R55) noted hitting and kicking staff prior to bedtime this shift, (R55 continues) to keep standing up and attempting to walk without staff assistance. Staff (continue) to attempt to redirect (R55) and remind (R55) to wait for assistance. (R55) refuses and became physically aggressive with staff when trying to assist (R55). (R55) flipped over a chair in the dining room while other residents were present. (R55) made multiple attempts to put self on floor, however, staff witnessed and was able to intervene. (R55) went into management office and grabbed scissors attempting to throw them at staff but did not hit anyone. (R55) noted to be more calm. (R55) taken to bathroom and assisted into bed, remains in bed at this time without further incident. Nursing Notes document on 7/29/23 that R55 became combative with her spouse and staff and was sent to the local hospital for a psychiatric evaluation. Nursing Notes document R55 was returned to the facility on 7/30/23 with the diagnosis of Urinary Tract Infection and was started on an antibiotic. On 8/02/23, Nursing Notes document R55 was sent to the local Hospital again for attempting to hit other residents without contact and putting herself on her hands and knees on the floor but was returned to the facility the same day with a new antibiotic, after determining she was started on the incorrect antibiotic for the Urinary Tract Infection three days prior. Residents Affected - Few Nursing Progress Notes document R55 fell a total of nine times between 7/14/23 and 8/06/23, after starting the initial antipsychotic (Seroquel), and sustained a left hip fracture as a result of the last fall on 8/06/23. Seroquel and Zyprexa Manufacture's Prescribing Information cites patients on Seroquel/Zyprexa are at an increased risk of sedation, somnolence and dizziness, which could lead to falling. Both Seroquel and Zyprexa's Manufacturer Prescribing information contain a Black Box Warning citing that elderly patients with Dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. On 8/24/23 at 12:33 pm, V16 (Consultant Pharmacist) stated she completed a medication review for R55 on 8/01/23 and her only recommendation was that R55 needed an AIMS assessment, since she was taking two Antipsychotic medications (Zyprexa and Seroquel). V16 stated she did not address or question R55's use of dual antipsychotics or the increase in the dose of the Seroquel from 25 mg daily to 100 mg daily between 7/10/23 and 7/29/23. V16 confirmed that, if R55's Seroquel needed to be increased, it could have been increased by a smaller dose. V16 indicated she was unaware that R55 had fallen nine times between 7/14/23 and 8/06/23 and confirmed that elderly residents on antipsychotics are at an increased risk of falling. On 8/24/23 at 11:38 am, V2 (Director of Nursing) stated she is responsible for the over site of Psychotropic Medication use in the facility. V2 was unable to determine why R55's Seroquel was increased on 7/19/23, when she had no further behaviors since being sent to the hospital on 7/14/23, or the justification for R55 being given a onetime dose of Zyprexa 5 mg on 7/28/23. V2 noted that R55 did have significant behaviors on 7/29/23 but was unaware R55's Seroquel was doubled in dose and started on an additional antipsychotic (Zyprexa) the same day and indicated she would have requested a medication review by the physician and/or pharmacist for the use of dual antipsychotics. V2 was questioned regarding what non-pharmacological interventions staff attempted with R55, prior to increasing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 10 of 18 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 08/24/2023 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 dose of Seroquel and adding Zyprexa daily. V2 stated R55 was able to walk prior to falling and breaking her hip, so staff would take her outside, as R55 enjoyed that; however, R55 would not let staff guide her and she would want to get up from her wheelchair and grab at the fence. V2 indicated R55 would use a busy blanket or place silverware, but those things would only hold her attention for a short time. V2 concluded that some of R55's behaviors near the end of July 2023 could have been exacerbated by the fact that she had a Urinary Tract Infection, as that can increase confusion in some patients. 3. R30's Minimum Data Set (MDS) assessment dated [DATE] documents R30 is severely cognitively impaired, has verbal behavioral symptoms directed towards others 1 to 3 days per week, R30's behaviors are unchanged from the previous MDS assessment, and requires extensive assistance of two staff for bed mobility and transfers; is totally dependent on staff for locomotion on and off the unit, has limitation in range of motion to both upper extremities, and uses a wheelchair for mobility. R30's current care plan documents R30 has contractures to both hands, uses a mechanical lift for transfers, and can be resistive to care at times. In addition, R30's care plan documents that R30 has the behavior of yelling out help me and is not able to identify what she needs help with due to R30's diagnosis of dementia. This same care plan documents that R30 has severe cognitive deficits related to dementia, Alzheimer's disease, and has significant confusion. Further, R30's care plan documents that R30 has significant communication deficits related to dementia and Alzheimer's disease and is not able to make her needs known. R30's list of current diagnoses includes Alzheimer's Disease with late onset, Unspecified psychosis not due to a substance or known physiological condition, Major Depressive disorder, recurrent, severe with psychotic symptoms, Unspecified Dementia, unspecified severity, with other behavioral disturbance, anxiety disorder. R30's physician's orders (POS) dated 4/10/23 document R30's antipsychotic medication, Risperidone, was decreased from 0.25mg (milligrams) 1 tablet two times daily to 0.25mg 1/2 tablet two times daily on that date. However, R30's POS documents R30's Risperidone was again increased to 0.25mg 1 tablet two times daily on 7/6/23 related to R30's diagnosis of Depressive disorder, recurrent, severe with psychotic symptoms. R30's monthly behavior tracking record (dated 5/2023 - 8/2023) do not document any specific behaviors in which R30 is being monitored for. R30's monthly behavior tracking record dated 6/2023 - 7/2023 do not demonstrate R30 had an increase of behaviors to warrant the increase of R30's Risperidone from 0.25mg 1/2 tab two times daily to 0.25mg 1 tab two times daily. R30's monthly behavior tracking record documents that in the 36 days prior to R30's increase in Risperidone, R30 had the behavior of yelling/screaming on two occasions. R30's current monthly behavior tracking record dated 8/2023 documents that, so far this month, R30 has had the behavior of yelling/screaming on six occasions. On 8/22/23 at 9:30a.m. R30 was in her room lying in bed holding onto a baby doll. R30 was pleasant and calm but did not speak when spoken to. At 12:00p.m. R30 was in the dining room being fed by staff. R30 was calm, pleasant, and without behaviors. On 8/23/23 at 12:00p.m. R30 was in the dining room being fed by V14 (Certified Nurse Aide). R30 was calm, pleasant, and without behaviors. On 8/24/23 at 9:00a.m. V9 (Certified Nurse Aide) stated that R30 has the behaviors of yelling out random things such as I want to go to the park. V9 stated R30 often will repeat these random phrases over and over. V9 stated that she does not think R30 is distressed when she is yelling out these random statements. V9 stated that giving R30 one of her babydolls to hold when she is yelling out will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 11 of 18 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 08/24/2023 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 usually help calm R30 down. Level of Harm - Minimal harm or potential for actual harm R30's Nurse Practitioner's progress note dated 8/22/23 documents R30's primary diagnoses are late onset Alzheimer's disease with behavioral disturbances, and dementia with behavioral disturbances. Residents Affected - Few On 8/23/23 at 9:14a.m. V2 (Director of Nurses) stated she manages residents' antipsychotic medications to ensure diagnoses and symptoms warrant the use of antipsychotic medications. V2 stated gradual dose reductions and dose adjustments are recommended by the facility's pharmacist. V2 was unable to provide what behaviors warranted R30's Risperidone increase on 7/6/23 but stated she thinks R30's behaviors are much improved with the increase in R30's antipsychotic medication. 2. R16's current Diagnoses includes the following: Schizophrenia and Major Depressive Disorder. R16's current Physician's Order Sheet documents the following orders: Risperidone Tablet 4mg (milligrams) give one tablet by mouth one time a day related to Schizophrenia, give with a 3mg tab to equal 7mg daily dose (date of order 06/07/22); and Risperidone tablet 3mg give one tablet by mouth one time a day related to Schizophrenia, give with a 4mg tab to equal 7mg daily dose (date of order 06/01/23). On 08/21/23 at 11:23 AM, R16 was lying in bed watching television. R16 was dressed, groomed and wearing glasses. R16 denied having concerns at this time. R16 stated he has a history of, mental problems a long time ago, and stated he feels he is currently stable. From 08/21/23 - 08/24/23, R16 was observed on multiple occasions, and no adverse behaviors were displayed by R16. R16's Monthly Behavior Monitoring Records (dated 03/2023 - 08/2023) do not document any specific behaviors in which R16 is being monitored for, or any adverse behaviors displayed by R16 during this time. R16's Progress Notes (dated 02/01/23 - 08/24/23) do not document any adverse behaviors were displayed by R16 during this time. R16's current care plan has no mention of any adverse behaviors that R16 displays. On 08/23/23 at 03:00 PM, V2 (Director of Nursing) stated she was unsure of any identified target behaviors displayed by R16. V2 stated R16 has not displayed any recent adverse behaviors. On 08/24/23 at 11:00 AM, V5 (Care Plan/Minimum Data Set Coordinator) stated she has worked at the facility for nearly one year and has never seen R16 display an adverse behavior. V5 stated she does not know any target behaviors displayed by R16. V5 then stated R16 is cooperative, and not a harm to himself or others. V5 stated a gradual dose reduction on R16's Risperidone has not been suggested or attempted since June 2022. V5 stated, He has not had any behaviors, so I am not sure why a GDR (gradual dose reduction) has not been attempted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 12 of 18 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 08/24/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure refrigerated foods were labeled with date opened, opened foods were stored in covered containers to prevent contamination, the kitchen floors were kept clean and free of debris, spills on the floor in the walk in cooler were cleaned, peeling paint was not hanging from the ceiling in food preparation areas, black spots were not covering the light fixture and ceiling above the ice machine, dust was not hanging from duct work over food preparation areas, and disinfectant used on the food preparation areas was the proper strength. These failures have the potential to affect all 56 residents in the facility. Findings include: A Food Storage policy dated 9/1/2021 states, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination, and All packaged and canned food items will be kept clean, dry, and properly sealed. In addition, this policy states, Storage areas will be neat, arranged for easy identification, and date marked as appropriate. A Sanitizer policy dated 9/2/2021 states, Sanitizer to be tested after dispensed before use. In addition, this policy states, The Dining Services staff will be knowledgeable in the proper technique for processing (facility) sanitizer, and All Sanitizer will be checked periodically for correct ppm (parts per million), at 200 PPM. On 8/21/23 V11 (Dietary Manager) was in the kitchen assessing the condition of the food preparation areas, refrigerators, freezer, and food storage areas. In the freezer located near a table in the kitchen were partially used bags of gluten free burgers, gluten free chicken patties, and waffle fries. None of these items were labeled with the date opened and the packages of gluten free burgers and chicken patties were not sealed with the contents left open to air. V11 verified all opened foods are supposed to be resealed once open and a date opened label is supposed to be affixed to the package/ container. Just outside the freezer on a rack of spices was a 3lbs (pounds) box of kosher salt which had the lid ripped open along the edge leaving the salt exposed to potential contamination. Around the periphery of the kitchen, and under a sink and ice machine was dirt, debris, and food crumbs. Inside the walk-in cooler, immediately in front of the door to the walk-in freezer was a frozen spill of orange material. V11 stated that another staff member spilled orange juice, but it froze before they were able to clean it up. In the dry storage area, there was an opened 25 lbs. bag of flour which was undated with the top of the packaging rolled down to close the bag. There were no staff in the back preparation area near the ice machine, yet there was shredded cheese and food debris on a preparation table. V11 stated that this was where dietary staff were preparing the raw chicken for the noon meal. There was a shelf next to this preparation table which contained an opened plastic bag of large tea bags which were unlabeled and left open to air. There was a 25 lbs. bag of dry breadcrumbs in the original bag which was open to air, undated, and the bag appeared to have been cut down from the top as the breadcrumbs were being used. There was dust hanging from the ductwork located in a crisscross fashion throughout the kitchen with some of the dust hanging directly over the steam serving table. There was a piece of paint peeled back and hanging down over the food preparation area where dietary staff were preparing a cheesecake dessert. There were many blackened spots covering the ceiling and light fixtures above the dishwashing station, food preparation area, and ice machine. At 10:05a.m. V11 verified the hanging dust, peeling paint, and black spots on the ceiling stating that she had never really looked up at the ceiling before. V11 stated she does not believe the kitchen staff are responsible for ensuring there is not soiling or debris hanging from the ceiling or its (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 13 of 18 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 08/24/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many fixtures. At 10:10a.m. V12 (Dietary) was in the kitchen preparing to sanitize the food preparation areas. V12 proceeded to take a wet cloth from a sanitizing bucket to wipe down the food preparation surfaces. V12 was asked to test the concentration of the sanitizer to ensure it was the correct concentration. V12 used a test strip to dip into the sanitizer liquid then compared the color of the strip to the color diagram on the test strip bottle then stated the concentration of the sanitizer was 150ppm. V12 stated that the sanitizer was at the correct concentration which was a range of 150-200ppm. A manufacturers information poster located on the wall next to the sanitizer dispenser clearly showed that the concentration of the sanitizer was supposed to be 200ppm to properly sanitize food preparation surfaces. On 8/23/23 at 3:04p.m. the large refrigerator located in the dining room contained a tray of fruit cups and servings of cheesecake which was undated. There was another bowl of opened canned fruit in juice which was unlabeled and uncovered. V11 verified the foods on the trays in that refrigerator were opened and unlabeled. The Resident Census and Conditions of Residents form, dated 8/21/2023 and signed by V5 (Care Plan/Minimum Data Set Coordinator), documents 56 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 14 of 18 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 08/24/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly dispose of garbage which has the potential to affect all 56 residents in the facility. Residents Affected - Many Findings include: A Housekeeper job description policy form (undated) states that housekeeping duties include, Empties, cleans and relines wastebaskets and places bags in receptacle to be transported to dumpster, and Cleans entrances and exits. A grievance log dated 7/31/23 documents that R10 complained to the facility about cleanliness. On 8/24/23 at 8:45a.m. R10 stated that he complained to the facility that there was always trash just outside the door near the dining room which leads to a [NAME] where residents like to sit with their visitors. R10 stated that the trash and cigarette butts are visible to residents as they come and go to the dining room for meals and activities. R10 stated that area is not pleasant to look at. R10 stated the window to his room faces the [NAME] and he can see the overflowing trash can from his bedroom window too. R10 stated he regularly looks out his window at the birds and deer who [NAME] around his birdfeeders. On 8/24/23 at 8:55a.m. the trashcan outside the glass door near the dining room was full of trash with an additional full trash bag placed on top of the already full trashcan. There were two empty disposable moistened washcloths boxes next to the trash can and a larger box with loose garbage in it placed on the ground on the other side of the trash can. There was a smaller concrete trash can which was full and overflowing next to the larger trash can. There were cigarette butts littering the ground all around the trash cans and boxes. The lid to the larger trash can was open and hanging down. The top of this lid had a sign attached which stated, Only Nursing Garbage Goes in This Container. There was a roll of clear trash bags under the wheels of the larger trash can. V8 (Licensed Practical Nurse) was inside the building preparing to pass medications to residents. V8 approached the glass door and verified the condition of the overflowing trash cans, cigarette butts, and empty boxes. V8 stated that residents and staff smoke outside in that area and nursing staff dispose of garbage in the larger garbage can. V8 stated that staff should have taken the overflowing garbage to the dumpster located around the side of the building from the [NAME] area. On 8/24/23 at 2:39p.m. V1 (Administrator) verified that R10 had complained about cleanliness in the facility. V1 stated that nursing staff use the garbage containers to empty waste generated during the day. V1 verified that residents also use that area outside the dining room including for smoke breaks. V1 stated in response to R10's concerns about the garbage outside the facility near the [NAME], (R10's) particular. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 15 of 18 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 08/24/2023 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a binding arbitration agreement was thoroughly explained and residents understood its meaning prior to obtaining a signature for two of three residents (R58, R59) reviewed for binding arbitration in a sample of 24. Residents Affected - Few An Arbitration Tracking Log dated 6/2/23 to 8/22/23 documents that R58 and R59 were admitted to the facility on [DATE], and both accepted the binding arbitration agreement. R58 and R59's Electronic Agreement to Arbitrate Health Care Negligence Claims Notice to Patients forms dated 7/8/23, with electronic check marks in the acceptance box, documents both R58 and R59 signed the facility's arbitration agreement 7/8/23 which states, This agreement provides that any claims which may arise out of your health care will be submitted to a panel of arbitrators, rather than to a court for determination. This agreement requires all parties signing it to abide by the decision of the arbitration panel. These same agreements document they were not signed by a witness until 7/13/23 for R58 and 7/11/23 for R59. R58's admission progress notes dated 7/6/23 document R58 was alert and oriented at the time of admission to the facility. R59's admission progress notes dated 7/6/23 documents R59 was alert and oriented but forgetful at times at the time of admission to the facility. On 8/24/23 at 9:42a.m. R58 and R59, who are roommates, were lying in their beds resting. Both R58 and R59 appeared oriented to time, place, and person, and were able to answer questions appropriately. R58 and R59 stated when they were admitted to the facility, there were documents that had to be signed, but neither R58 nor R59 remember receiving education explaining what a Binding Arbitration agreement means. R58 stated that R58 wants the ability to bring legal action against the facility if the need arises. R59 stated that R59 is retired from working in the legal field and would never have signed a Binding Arbitration agreement had it been properly explained. Both R58 and R59 stated that not until after they signed their admission contracts with the facility; did they designate a family member as their Power of Attorney (POA), and therefore, they signed all of their own admission documents. On 8/24/23 at 9:52a.m. V1 (Administrator) stated that sometimes the facility's admission paperwork can be overwhelming to newly admitted residents. V1 stated that perhaps R58 and R59 read the Arbitration agreement but didn't understand what they read and/or signed the agreement without understanding what they were signing. V1 stated that V1 thinks that sometimes residents are given information such as the Arbitration agreement too soon after admission when they have so much information given to them at once and they don't remember everything they signed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 16 of 18 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 08/24/2023 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 interview and record review, the facility failed to conduct annual testing to rule out the presence of opportunistic waterborne pathogens in the facility's water system. This failure has the potential to affect all 56 residents currently residing in the facility. Residents Affected - Many Findings Include: The facility's Legionella Water Management Program (revised July 2017) documents, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. A final report from a local water treatment company (dated 11/25/2020), documents the following result after the facility's water system was tested, Analytical Report, total Legionella- Not detected. On 8/24/2023 at 10:30 AM, V1 (Administrator) indicated the facility has not tested their water system for the presence of Legionella since 2020 and stated, I am unable to locate any other yearly testing. 2020 is the last year I have test results available. On 8/23/2023 at 11:15 AM, V6 (Maintenance Director) stated, I knew nothing about this Legionella testing, until yesterday, it was brought to my attention. I was gone for a while and just came back in February. I knew nothing about this, so the testing did not get done. (V15, Corporate Maintenance) was doing things around here when there was no maintenance man here. It just did not get done. The Resident Census and Conditions of Residents form, dated 8/21/2023 and signed by V5 (Care Plan/Minimum Data Set Coordinator), documents 56 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 17 of 18 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 08/24/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review the facility failed to ensure dining room ceiling tiles located directly over residents' dining tables were clean, free of dark stains and not bulging. This failure has the potential to affect all 56 residents in the facility. Findings include: A General Maintenance and Monitoring policy dated 9/15/19 gives as its purpose, To provide guidelines on maintenance rounds for facility upkeep to maintain a safe and hazard free environment. In addition, this policy states, The maintenance Director is responsible for upkeep and repair of facility equipment, and The Administrator will monitor that repairs are completed in a timely manner. On 8/21/23 at 12:21p.m. the ceiling in the center of the dining room, directly above where residents were eating their noon meal, had a brownish black discoloration in a ring pattern with two of the tiles severely bulging downward. These ceiling tiles remained in the same condition throughout the survey from 8/21/23 to 8/24/23. On 8/22/23 at11:45a.m. V4 (R37's family) stated, The dining room has some ceiling tiles that need replaced. It looks like some of the tiles have black mold on them. They need to be changed. On 8/23/23 at 2:00p.m. V1 (Administrator) verified the dining room ceiling tiles are discolored and bulging. V1 stated that the tiles became stained a few weeks ago from sweating from the pipes in the ceiling located above the tiles. V1 stated that the problem with the pipes is ongoing, and the facility has not replaced the stained ceiling tile because the new tile would become wet from the pipes. In addition, V1 stated the ceiling tiles have already been ordered but just haven't arrived at the facility yet. On 8/24/23 at 11:45a.m. V6 (Maintenance Director) verified the ceiling tiles in the dining room directly above where residents eat their meals had brown and black circular stains with two of the tiles severely bulging. V6 stated that the tiles were just ordered from a building supply store that morning. V6 stated the facility was waiting for the owner to approve of the purchase before ordering the new tiles. V6 stated the tiles became wet from the pipes in the ceiling sweating and dripping onto the tiles. The Resident Census and Conditions of Residents form dated 8/21/2023 and signed by V5 (Care Plan/Minimum Data Set Coordinator), documents 56 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145691 If continuation sheet Page 18 of 18