Health inspection·February 24, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yellow eyes and pale skin. Resident has a slurred speech and appears lethargic, oriented to self, vital signs 105/80, Pulse 78, Spo2 (oxygen saturation level) 78% on room air, DON, POA (Power of Attorney), and MD notified. R39 left the facility at 1:00 AM with two assists On 2/23/23 2:52 PM, V2, Director of Nursing (DON), stated on 12/10/2022, CNA found a blue pill on resident's bed and the blue pill was compared to resident's current medications and did not match any other medications. On 2/23/23 2:45 PM, V1, Administrator, stated family was bringing in Tylenol PM in a baggie. The facility was not aware until a CNA (name not documented) found a blue pill on resident's bed that did not match any of her medications. The facility did a room search on 12/12/2022, and found the Tylenol PM tablets. V1 stated (R39) had a package delivered and V5, Social Service Director, told V1 she thought medications were in the package, because the package was making a rattling sound. V5 went to resident's room and (R39) was in the therapy room. V5 went to the therapy room and asked (R39) to open the package. (R39) opened the package and said, I ordered the melatonin. V5 told R39 she could not have medications or order medications without a doctor's order. R39 told V5 she did not know she needed an order from the doctor. V5 took the medications to the nurse, and the nurse locked the medications in the med room. V1 stated the facility got a physician's order for the melatonin. The Facility's Change of Condition Notification Policy, revised 10/7/2022, documents the resident's physician will be notified of any changes that occur in the resident's condition by licensed personnel as warranted. These changes are to include change in level of consciousness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to have a Registered Nurse working 8 hours a day, 7 days a week. This failure has the potential to affect all residents in the facility. Residents Affected - Many Findings include: On 2/21/2023 at 10:36 AM, V1, Administrator, stated (V2) Director of Nursing (DON) is the only Registered Nurse (RN) on the schedule. V2 works 8-10 hours a day Monday through Friday. They do not have RNs 8 hours a day that work Saturdays or Sundays. They are actively looking for a weekend RN, but they haven't had any luck. On 2/22/2023 at 2:25 PM, V2, DON, stated she works Monday through Friday, from 8:00 AM to 6:00 PM; she doesn't work Saturday or Sunday. The facility's daily staffing sheets from 2/7/2023 through 2/24/2022 document no RN worked on the weekends. On 2/24/2023 at 12:38 PM, V1 stated the facility doesn't have a policy for an RN 8 hours a day 7 days a week; they follow state guidelines on RN staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen to prevent contamination of the ice. This has the potential to affect all 41 residents living in this facility. Findings include: On 2/22/23 at 8:00 AM, the drain hose from the ice machine was down inside the drain hole in the kitchen floor, along with the hose coming off the furnace. There was no air gap between the drain hole and the drain hose from the ice machine. On 2/22/23 at 10:45 AM, V3, Dietary Manager, stated the ice machine in the kitchen is the only ice machine in the facility, and is used for all the residents in the facility. On 2/22/23 at 10:48 AM, V6, Maintenance Supervisor, stated he is not really sure how much of an air gap there is supposed to be between the drain and the drainage hose from the ice machine, but he thinks it's about 3 or 4 inches. V6 stated he doesn't know how long the drainage hose has been down inside the drain, but they just replaced the ice machine a couple of months ago, so they may have set it up that way at the time they put it in. V6 stated he did not have a specific routine for checking proper placement of the drainage hose coming from the ice machine to make sure there is an air gap. V6 stated the facility does not have a policy regarding what the air gap for the ice machine drain hose should be. Section 890.1040 of the 77 Illinois Administrative Code 890 Air Gaps documents: The air gap between an indirect waste and the drainage system shall be at least two (2) times the diameter of the fixture drain or drainage pipe served, but shall never be less than (1) one inch. The facility's Resident Census and Conditions of Residents form 672, dated 2/21/23, documents there are 41 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 perform hand hygiene and maintain adequate infection control practices to prevent cross contamination for 2 of 41 residents (R33, R34) reviewed for infection control in the sample of 46. Residents Affected - Few Findings include: On 2/23/ 23 at 9:50 AM, V8, Licensed Practical Nurse (LPN), provided wound care treatment to R34. V8 placed a disposable pad under R R34's feet. V8 removed the wound dressing and observed blood and green drainage on the bandage. Blood dripped from wound onto the disposable pad. V8 placed scissors and wound cleanser bottle on the pad where blood was dripping from R R34's wound. V8 did not wash her hands or use hand sanitizer going from the dirty to clean wound dressing. V8 did not clean wound cleanser bottle after providing treatment care. V8 placed the contaminated wound cleanser on roommate's (R33's) nightstand. V8 did not clean roommate's table after placing the contaminated wound care cleanser bottle on roommate's table. V8 placed the contaminated wound care cleanser bottle in the bottom of the treatment cart, exposing the other items in drawer. V8 did not wash hands or use hand sanitizer before leaving R34's room. On 2/23/23 at 9:42 AM, V8 stated R34 is on Isolation for Methicillin resistant Staphylococcus aureus (MRSA). On 2/24/23 at 11:22 AM, V2, Director of Nursing (DON), stated she expects the staff, and nursing staff, to wash hands, and not to cross contaminate. She expects the nurse to cleanse the wound cleanser bottle and not place the dirty bottle in the treatment cart. V2 stated V8, LPN, should not have placed the dirty wound cleanser bottle on R34's roommate nightstand. R34's Lab Report, dated 12/8/22, documents culture results in aerobic blood culture Methicillin Resistant Staphylococcus Aureus (MRSA). The Hand Hygiene policy, dated 9/4/2020, documents to provide guidelines for adequate hand washing in order to reduce the transmission of organisms from resident to resident, staff to resident, and from resident to staff. The facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed. Employees must wash their hand for twenty (20) full seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct contact with residents, when hands are visibly dirty or soiled with blood or other body fluids, after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin, after removing gloves, after handling items potentially contaminated with blood, body fluids, or secretions. Hand hygiene is always the final step after removing and disposing of personal protective equipment. The Infection Control policy, dated 5/21/2022, documents to provide guidelines for all staff regarding the facility established infection control program that investigates, controls and prevents infections. Surveillance for nosocomial infections will be done to provide a format for the surveillance of infections of infections occurring within facility. The facility will establish and maintain the program to provide a safe and sanitary environment, and to help prevent the development and transmission of disease and infection. Infections will be investigated, controlled, and prevented, and isolation precautions will be determined on an individual basis. The Infection Report Form will be kept (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 on those residents who are receiving antibiotics or have an infection. Level of Harm - Minimal harm or potential for actual harm It is the responsibility of the Licensed Nurse/nursing staff to follow the policy to ensure proper identification and containment of infections. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide adequate tracking for antibiotic stewardship surveillance to monitor for patterns and trends in infections and antibiotic use for 4 of 4 residents (R12, R13, R20, R94) reviewed for antibiotic stewardship in the sample of 46. Residents Affected - Some Findings include: 1. The facility's document, Monthly Infection Control Log (Line List), dated July (No year), documented; had requested Infection Control Log for past year) documents R12 was diagnosed with a Urinary Tract Infection (UTI) and Colitis, but does not document the date of the onset of the infection, or identify the organism/pathogen causing the infection. The Infection Control Log documents R12 was ordered Levaquin on 7/28/22. R12's Urine Culture and Sensitivity Report, dated 7/27/22, documents the causative pathogen as Klebsiella oxytoca ESBL (Extended Spectrum betalactamase). R12's Physician Order Summary (POS), dated 2/24/23, documents the order, dated 7/29/22: Levaquin 500 milligrams (mg) daily for 5 days for infection. 2. The facility's document, Monthly Infection Control Log (Line List), dated November 2022, documents R13 was diagnosed with a UTI, with the date of onset of 11/9/22, but it did not document the organism/pathogen causing the infection. It documents R13 was ordered Levaquin to be started on 11/11/22. R13's Urine Culture Report, dated 11/10/22, documents the causative organism/pathogen for his UTI as Citrobacter freundii and Streptococcus agalactiae. R13's POS, dated 2/24/23, documents the order, dated 11/11/22: Levofloxacin 750 mg every 48 hours for kidney injury until 11/29/22. 3. The facility's document, Monthly Infection Control Log (Line List), dated September 2022 documents R20 was diagnosed with a UTI on 9/30/22, but it did not document the organism/pathogen that caused the infection. According to the log, R20 was ordered Bactrim on 10/1/22. R20's Microbiology Report, dated 9/30/22, documents the source as urine and the pathogen for R20's UTI as Klebsiella pneumoniae. R20's Medication Administrator Record (MAR), dated October 2022, documents the order dated 9/30/22 : Bactrim 800-160 mg one every 12 hours for bacterial infection. R20's September and October MARs does not document R20 received her dose of antibiotics on 9/30/22 or 10/4/22. 4. The facility's document, Monthly Infection Control Log (Line List) dated October 2022 documents R94 was diagnosed with a UTI, with the onset date of 10/19/22, but the log does not identify the organism/pathogen that caused the infection. The log documents R94 was ordered Keflex on 10/19/22 to treat the UTI. R94's Microbiology Report, dated 10/20/22, documents the pathogen causing her UTI was Escherichia coli. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R94's Physician Order Summary, dated 2/24/23, documents the order, dated 10/19/22: Keflex 500 mg three times a day for UTI until 10/25/22. On 2/24/23 at 10:15 AM, V2, Director of Nursing (DON), stated, Since I took over, I am making sure we have the culture and sensitivity report to ensure the residents with UTIs or other infections are receiving the appropriate treatment, but I know the Infection Control Log did not have all the required information on it before I took over. I make sure all the information is on the Infection Control Log each month and use this to track and trend infections in the facility. On 2/24/23 at 1:20 PM, V2 provided a facility floor plan with UTIs, respiratory infections and skin infections identified, but no causative organism/pathogen identified for any of these infections; therefore no information available for tracking and trending of like organisms being identified . The facility's policy, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes undated, documents, Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. It continues, 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic (see approved surveillance list); e. Start date of antibiotic; f. Pathogen identified (see approved surveillance list); g. Site of infection; h. Date of culture; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 0881 i. Level of Harm - Minimal harm or potential for actual harm Stop date; j. Residents Affected - Some Total days of therapy; k. Outcome; and l. Adverse events. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 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 145769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in multiple resident bedrooms. This has the potential to affect all 41 residents living in the facility. Findings include: The facility has a total of 25 resident rooms. Each of these two-bed resident rooms have less than 80 square feet of floor space for each resident, according to the facility document, Resident Room Square Footage, dated 2/21/20. Two rooms, rooms [ROOM NUMBERS], are currently being used as a dining room. On 2/23/23 at 10:30 AM, 1 of these two-bed resident's rooms, measures 72 square feet. The resident residing in this room is R22. On 2/23/23 at 10:30 AM, 2 of these two-bedroom resident's rooms, measure 77 square feet per resident's bed. The residents residing in these rooms are R9, R25, and R30. On 2/23/23 at 10:30 AM, 6 of these two-bed resident's rooms, room [ROOM NUMBER], 5, 7, 21, 22, and 23 measure 78 square feet per resident's bed. The residents residing in these rooms are R6, R14, R24, R27, R28, R29, R31, R32, R37, R141, and R142. On 2/23/23 at 10:30 AM, 14 of these two-bed resident's rooms, measure 79 square feet per resident's bed. The residents residing in these rooms are R1, R2, R3, R4, R5, R7, R8, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R26, R33, R34, R35, R90, R91, R92, R93, R140, and R190. On 2/23/23 at 9:30 AM, V1, Administrator, stated there have been no changes to the room sizes, and all the rooms have been covered by a room waiver the facility requested the previous year. The facility's Resident Census and Conditions of Residents, CMS 672, dated 2/21/23, documents there are 41 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 10 of 10