Health inspection·January 23, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/17/24 at 3:37PM, R4 was transferred from her wheelchair into her bed, with assistance of two nursing staff, V14 and V15, both Certified Nurse Aides (CNA's) using a full mechanical lift, removed R4's soiled pants, and bowel movement soiled incontient brief. R4's was placed at the window side, with window blinds open, and multiple plants in the windowsill, and a divided curtain from R4's roommate was not closed to provide privacy. On 1/18/24, V4 CNA/Business office Manager, stated she would expect privacy be provided to any resident during care services. 4. R18's, Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact. On 1/16/2024 at 10:25 AM, V12, CNA, was repositioning R18 to her left side. R18's bare buttocks were exposed towards the door of R18's room, facing the hallway. At this time, another unknown staff member knocked on R18's door and opened it, requesting the mechanical lift. At this time,V11, CNA stated R18 should have a curtain to provide privacy, and she would let maintenance know. On 1/17/2024 at 9:30 AM, R18 still did not have a privacy curtain. On 1/17/2024 at 11:53 AM, R18 stated, I would like a curtain. It does bother me. That is my only complaint about my care, especially since there is a man across the hall. On 1/17/2024 at 2:14 PM, V7, Licensed Practical Nurse (LPN), stated her and V11, CNA, discussed R18's need for a privacy curtain and added, especially since there are men across the hall. V7 continued to state, If we open the door and she is on her side, she is exposed. We try to cover her but if the person outside the door doesn't know . On 1/18/2024 at 1:32 PM, V1, Administrator, stated R18 should have a curtain for privacy. The Facility's Dignity Policy, dated 9/15/2019, documents, All residents will be treated with dignity and respect. Federal and State laws guarantee certain basic rights to all residents of this facility. It continues to document residents have the right to privacy and confidentiality. Based on observation, interview, and record review, the facility failed to provide privacy and dignity for 4 of 9 (R4, R18, R31, R33) residents, reviewed for resident rights, in a sample of 45. Findings include: Page 1 of 15 145769 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0550 Level of Harm - Minimal harm or potential for actual harm 1. R31's face sheet, dated 1/18/24, documented R31 was admitted to the facility on [DATE], with diagnosis of dementia, type 2 diabetes, dysphagia, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side, aphasia, osteoarthritis, hypertension, atherosclerosis, peripheral vascular disease, cardiomyopathy, and atherosclerosis. Residents Affected - Some R31's Minimum Data Set (MDS), dated [DATE], documented R31 is severely cognitively impaired. R31's Care Plan, dated 3/21/23, documented R31 requires extensive assistance with Activities of Daily Living (ADLS) and requires one-person physical assistance with eating. On 1/16/24 at 12:15 PM, R31's lunch was served to her in the dementia unit. At 12:57 PM, R31 had not taken any bites of her lunch, and V9, Certified Nurse Assistant (CNA), fed R31 a few bites of food, while V9 was standing beside R31. The dementia unit did not have any additional chairs for the facility staff to sit in when assisting residents with eating. 2. R33's face sheet, dated 1/18/24, documented \R33 was admitted to the facility on [DATE], with diagnosis of dementia, Alzheimer's disease, atherosclerosis, congestive heart failure, chronic kidney disease, and osteoarthritis. R33's MDS, dated [DATE], documented R33 is severely cognitively impaired. R33's care plan, dated 11/26/22, documented R33 requires extensive assist with all ADLS and requires one-person physical assistance with eating. On 1/16/24 at 12:46 PM, R33 was sitting in his wheelchair in the dementia unit dining room. R33 was not feeding himself. V9, CNA, verbally cued R33 to eat. R33 did not respond to the verbal cues. V9 then fed R33 some of his lunch. V9 was standing while feeding R33. The dementia unit dining room did not have any additional chairs for the facility staff to sit in when assisting residents with eating. On 1/22/24 at 8:30 AM, V1, Administrator, stated she would expect the CNA's to be sitting while feeding residents. The facility policy for feeding the dependent resident, dated 9/15/19, documents 4. When feeding in dining room: A. Identify resident. B. Ensure that proper diet is being served. Check tray card to content of plate. C. Ensure proper consistency. D. Position resident for comfort. E. Protect clothing with clothing protector. F. If the resident cannot see the tray, tell him/her the position of each item on the tray. G. Cut or divide food into small portions and give resident a small amount at a time. Do not force the resident to eat. H. Do not discuss unpleasant subjects while the resident is eating. I. Never make the resident feel that the meal must be hurried, but that the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident when possible. 145769 Page 2 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain the building in good repair for 11 of 13 (R2, R6, R10, R14, R19, R19, R26, R29, R31, R33, R36, and R37) of 13 residents, reviewed for a homelike environment, in a sample of 46 reviewed for a homelike environment. Findings include: On 1/16/24 at 10:00 AM, during the facility tour of the dementia unit, the following maintenance concerns were observed: 1. R19 and R31's had multiple missing floor tiles in room. 2. R14 and R29's room had multiple missing floor tiles, the closet door was off the track, and the peach-colored painted walls were covered with white dry wall patches throughout the entire room. 3. R2 and R26's room hadroom had multiple missing floor tiles, the wall paint was chipped in multiple areas throughout the room, and the closet doors were off the track. 4. R37's room was missing the closet doors. 5. R33 and R36's room had multiple areas of wall damage with torn and missing wallpaper, the trim on the middle of the wall was missing revealing damaged drywall, the bathroom door and door jamb had multiple areas with rust coming through the white paint; the bathroom had missing floor tiles, the base of the bathroom vanity cabinet was rusty and coming apart, the closet doors were off the track and the track was damaged and the bedside table was stained and chipped. 6. R6 and R10's room had base board off the wall, there was broken sheet rock at the base of the wall, multiple damaged and missing floor tiles, the closet door was missing on one side of the closet and the bathroom door jamb and bathroom door had multiple areas of rust coming through the paint. On 1/16/24 at 11:55 AM, V9, Certified Nurse Assistant (CNA), stated the facility has an app (application) they are supposed to use to notify the maintenance department of repairs needed, but no one ever uses the app. V9 continued to state she just lets the new maintenance man know if something needs fixed. On 1/18/24 at 9:40 AM, V19, Maintenance Director, stated the staff tell him or leave him a note if something needs fixed. V19 continued to state he does not having any ongoing maintenance plans for the dementia unit, other than he might remodel the shower. The Maintenance Guarding Angel Rounds documents, dated 12/1/23 through 1/22/24, did not document any of the needed repairs on the dementia unit. The facility's General Maintenance and Monitoring Policy, undated, documented, The purpose of the policy is to provide guidelines on maintenance rounds for facility upkeep to maintain a safe and hazard free environment. The guidelines are to: 1. The Maintenance Director is responsible for upkeep and repair of facility equipment. 2. Staff are to notify Maintenance verbally or using a work order maintenance request concerning any equipment, furniture, general maintenance concerns. Maintenance 145769 Page 3 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needs to follow up with the repairs based on the priority in a timely manner. 3. The Maintenance Director will complete daily environmental rounds of the facility to observe any needed repairs. 4. The Administrator and the Maintenance Director will complete monthly rounds to further observe for any environmental or equipment issues. 5. Department Heads will also be responsible for monitoring and reporting any concerns related to the equipment and environment at the daily morning meeting. 6. The Administrator will monitor that repairs are completed in a timely manner. 145769 Page 4 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, monitor, and treat a wound for 1 of 4 (R9) residents, reviewed for repositioning, in a sample of 45. This failure resulted in R9 obtaining a wound to her coccyx, buttocks, and causing R9 to experience pain. Residents Affected - Few Findings include: R9's admission Profile, print date of 1/22/4, documented R9 was admitted on [DATE], with diagnosis of Unspecified Fracture of Third Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Displaced Fracture of greater Trochanter of Left Femur, subsequent encounter for closed fracture with routine healing, Chronic Obstructive Pulmonary Disease. R9's Care Plan, dated 1/9/24, documented, (R9) has the potential for impaired skin integrity related to incontinence, limited mobility. It continues Pressure redistribution mattress to bed. Provide diet as ordered. Labs as ordered. Evaluate Skin at least Weekly. Medications as ordered. R9's Minimum Data Set, dated [DATE], documented R9 is severely cognitively impaired, frequently incontinent of bowel and bladder, and requires moderate assist of staff to reposition in bed and no skin impairment. On 1/16/2024 from 9:50 AM to 12:50 PM, with 15-to-30-minute intervals, R9 was lying in the bed on her back. On 1/16/2024 at 9:40 AM, V17, Certified Nurse's Assistant (CNA), stated R9 has not been doing well. V17 also stated R9 has been weak and was not feeding herself. On 1/16/2024 at 9:50 AM, R9 stated she has a sore on her bottom, and it hurts. On 1/17/2024 at 9:10 AM, R9 was lying in bed on her back, with a partially eaten tray on bedside table, out of R9's reach. On 1/17/2024 at 9:12 AM, R9 had facial grimacing, and stated her bottom hurts. R9 attempted to shift weight, unsuccessfully. R9 stated she was not able to turn herself. R9 stated, I can't get off my butt. It hurts really bad. On 1/17/2024 at 9:17 AM, V17, CNA, informed R9 after she finishes with her food, she would reposition her. On 1/17/2024 at 9:21 AM, V17, CNA, and V18, CNA, performed incontinent care. R13 was incontinent of urine and bowel. V18 cleansed R9's peri area. V17 and V18 then turned R9 onto her left side exposing R9's bottom. R9's buttock was fire engine red, with deep linear indentations. A pressure ulcer measuring approximately 0.5cmx1cm x0.2cm (centimeters) was observed to the coccyx area. On 1/17/2024 at 9:21 AM, V17, CNA, stated the pressure ulcer was not there yesterday. V17 stated R9's buttocks have been red, but not open. On 1/18/2024 at approximately 10:00 AM, R9 was lying on her left side with buttocks exposed. R9's 145769 Page 5 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0684 sacrum, coccyx, and buttocks, were red in color, and no treatment in place to the pressure ulcer. Level of Harm - Actual harm On 1/18/2024 at approximately 2:15 PM, R9 stated she was still having pain to her buttocks. R9 stated she could not give a number on a scale, but that it hurt a lot. Residents Affected - Few On 1/18/2024 at 3:00 PM, when asked what they were doing about R9's pressure ulcer, V1, Administrator, and V3, Regional Clinical Nurse, both stated they were not aware of R9 having a wound. On 1/22/24 at 1:02 PM, V13, Licensed Practical Nurse/LPN, stated she was not notified of R9 having the open area until Friday. V13 stated the process when finding a new wound is that the aide will notify the nurse immediately. V13 stated she would then assess the resident. V13 stated she would notify the doctor and hospice nurse. V13 stated R9 now has a treatment to her area, and that it's changed every 72 hours. On 1/23/2024 at 1:05 PM V23, Nurse Practitioner, stated she was made aware of R9 having an open wound on Friday. V23 stated she saw the area on Friday and today. V23 stated she believes the area was due to R9 overall decline related to bronchitis. V23 stated she believes the area was caused by moisture, related to R9 being incontinent of both bowel and bladder, which is a change for R9. V23 stated she would expect to be notified of the wound when first identified. V23 stated the treatment would start then. V23 stated R9 knows when she is in pain and can verbalize it. V23 stated not treating the wound would contribute to R9's pain. The Skin Protocol policy provided by the facility, not titled nor dated, documented, PURPOSE: To provide guidance to facility staff on the proactive approach to maintaining resident's skin integrity and the prevention/treatment of pressure ulcers. It also documents Preventative Measures: 1.Turning, positioning and pressure redistribution (off-loading) will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. 3. Minimizing exposure to moisture. 145769 Page 6 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide complete incontinent care for 2 of 4 residents (R4, R13) reviewed for incontinent care, in a sample of 45. Findings include: 1. R4's, Care Plan, dated 11/23/22, documented, (R4) requires extensive care assistance, due to a medical diagnosis of dementia, impaired mobility, weakness with incontinence of bowel and bladder. R4's, Physician Orders, dated 1/17/2024, documented R4 receives iron supplement tablet, 325 milligrams (mg) every morning and evening for Anemia. On 1/17/24 at 3:37 PM, R4 was transferred from her position in a wheelchair into her bed, with assistance of two nursing staff, V14 and V15, both Certified Nurse Aides, (CNA's), using a full mechanical lift. After laid flat on her back in bed and left pant leg up, R4's left lower ankle was exposed, revealing dark black dried streaks. V14 and V15 washed their hands, and placed on clean gloves. V14 was on R4's on left side of bed, and V15 on R4's right side of bed. They removed R4's pants and soiled incontinent brief. R4 was heavily soiled with black, thick bowel from her front perineum area, inner lateral thighs, and streaks of black stool down her inner left thigh to her ankle and in between her toes. V14 and V15 positioned R4 to her left side, as V14 cleansed R4's perianal area. During R4's cleansing, V14 had stool on her gloves; V14 folded the wet wash cloth and continued to clean R4's buttock. Then V14 changed her soiled gloves, placed on clean gloves, and placed R4 on her back to clean R4's front side. At this time, V14 and V15 stated they needed more wash cloths to clean R4. V15 changed her gloves, washed her hands, and left the room to get more clean wash cloths, and V15 re-entered the room. During this time, V14 and V15 discussed who is now dirty and who was clean to complete R4's incontinent bowel care. V14 then cleansed R4's front perineum area. R4 was heavily soiled with bowel movement from her perineum. V14 continued to use a wash cloth, folded cloth, and continued to cleanse; R4's inner labia folds were not cleansed, only partial. R4 was then positioned to her right side. V14 and V15 then placed a clean incontinent brief to R4. On 1/17/24 at 4:05PM, V14,CNA, and V15, CNA, both stated, they knew they did not do R4's incontinent care correctly. They both stated they came on their shift at 2:00PM, and they were immediately involved caring for another resident that was heavily incontinent of bowel, and they were only two CNA's to attend to these resident on this hall on the evening shift. 2. R13's MDS, dated [DATE], documented her cognition was severely impaired and that she was frequently incontinent of urine and feces. R13's Care Plan, dated 11/21/22, documented, One person physical assist required. On 1/17/2024 at 9:21 AM, V17, Certified Nurses Assistant (CNA), and V18, CNA, performed incontinent care. R13 was incontinent of urine. V17 and V18 assisted R13 into the bed using a standing mechanical lift. Using a wet washcloth and spray soap, V18 cleansed R13's peri area. V17 and V18 then assisted R13 onto her right side. V18, using a wet wash cloth, cleansed R13's entire left buttock and partial right buttock V18 then placed an incontinent brief partially behind R13 and assisted R13 onto her back. V17 and V18 then turned R13 onto her left side and pulled the incontinent brief completely 145769 Page 7 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behind R13. V17 and V18 then turned R13 onto her back and fastened the brief. V17 and V18 did not cleanse R13's entire right buttock. The facility' policy and procedure, entitled, Incontinence Care, dated, 9/15/19, documented, provide proper incontinence are in order to clean skin clean, dry. wash all soiled skin areas and dry very well, especially between skin folds. 145769 Page 8 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, observation, and record review, the facility failed to employ a Registered Nurse (RN) in the role of full time Director of Nursing (DON), and to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 43 residents residing in the facility. Finding includes: There was no consecutive 8-hour RN coverage in 24 hours for the entire Month of October 2023, 11/1, 11/2, 11/4 to 11/30, the entire month of December 2023 and 1/1/2024 to 1/15/2024. On 01/16/24 at 1:38 PM, V9, Certified Nursing Assistant (CNA), stated \V1, Administrator, is also the DON (Director of Nursing). On 1/16/2024 at 11:40 AM, V10, CNA, stated V1 is also the facility DON. On 1/16/2024 at 1:40 PM, V1, Administrator, stated they do not have RN coverage. V1 stated they are actively recruiting for RNs. V1 stated V3, Regional Nurse, comes to the building once or twice a week. On 1/16/2024 at 12:20 PM, V3, Regional Nurse, stated they are actively recruiting for the Director of Nursing position. V3 stated they did have a DON for a short time and she was not willing to perform the required duties of that facility and quit. On 1/16/2023 at 3:06 PM, V3, Regional Nurse, stated the facility does not have a staffing policy. V3 stated she follows the staffing guidelines. The facility's Resident Census and Conditions of Residents, CMS 672, dated 1/17/24, documents there are 43 residents residing in the facility. 145769 Page 9 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly store medication, and label tuberculin and insulin vials. This has the potential to affect all 43 residents living in the facility. Findings include: On 01/16/2024 at 10:07 AM, the facility's Medication Storage Room was inspected. The refrigerator located in the medication room contained the following: 1. 1- 5 ml open and partially used multi dose vial of Apisol. No open date on the box or the vial. The Apisol package insert, dated 3/2016, documents Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 1/16/2024 at 10:15 AM, the medication cart was inspected. The cart contained the following: 2. R2's open and partially used multi dose vial of Lantus. No open date. 3. R1's open and partially used multi dose vial of Lantus. No open date. On 1/2/2024 at 9:55 AM, V7, Licensed Practical Nurse (LPN), stated, The Apisol medication is a stock medication and used for all residents in the facility. Unless they have an allergy, all residents get an Apisol shot at least yearly. This would be the medication that would be used. V7 verified the multi dose vial was open and in use. V7 stated she had not used the insulin pen, as it is scheduled for evenings. V7 stated the pen, once put in use, should have the resident name on it and the open date. V7 stated the multi dose vial and the insulin pen have different expiration days once open. V7 stated the expiration date decreases. V7 stated the open date lets them know when that date is. V7 stated the Apisol and Lantus vials expire in thirty days after opening. On 1/17/2024 at 2:06 PM, V13, LPN, stated when opening the multi dose TB (tuberculin) and insulin vials, the open date is put on the box and the vial. V13 stated she is not sure of the exact date for the TB, but knows it is shorter than the manufacture. V13 stated the insulin vials are only good for 30 days. V13 stated the open date is placed to let them know when the medication has to used by. The facility's Storage of Medication, dated 1/1/21, documents the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The facility's Medication Administration Policy/Procedure Insulin Administration via vial Procedure, dated 9/27/22, documents General Guidelines Characteristics and Types of insulin 4. Check the expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date on the vial (follow manufacturer recommendations for expiration after opening.) The facility's Resident Census and Conditions of Residents, CMS 672, dated 1/17/24, documents there are 43 residents residing in the facility. 145769 Page 10 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the Facility failed to ensure the minimum required staff were present at the Monthly Quality Assurance Meetings. The failure has the potential to affect all 43 residents residing in the Facility. Residents Affected - Many Findings include: On 1/16/2024 at 12:20 PM, V3, Regional Nurse, stated they are actively recruiting for the Director of Nursing position. V3 stated they did have a DON for a short time, and she was not willing to perform the required duties of the facility and quit. On 1/22/2024 at 8:14 AM, V1, Administrator, stated the Quality Assurance team meets monthly and should include every department head. V1 added, When I get a DON (Director of Nursing), she'll be there. The Facility's Quality Management Program Meeting Verification Forms, dated 10/18/2023, 11/15/2023, and 12/20/2023, were reviewed, and did not include a signature/title for the DON position. The Resident Census and Conditions of Residents, CMS 671, dated 1/16/24, documents the facility has 43 residents living in the facility. 145769 Page 11 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0880 Provide and implement an infection prevention and control program. 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 wear appropriate personal protective equipment (PPE) as identified in Infection Control procedures, and failed to cleanse hands after removing gloves following resident incontinence care, to prevent/control spread of infection for 4 of 5 residents (R4, R9. R18 and R33) reviewed for Infection Control in a sample of 45. Residents Affected - Some Findings include: 1. R4's, Physician Orders, dated 1/17/2024, documented R4 receives iron supplement tablet, 325 milligrams (mg) every morning and evening for Anemia. R4's Care Plan, last revision date of 11/23/22, documented R4 requires extensive care assistance due to a medical diagnosis of dementia, impaired mobility, weakness; behavioral disturbance of screams and yelling; also, documented R4 receives only one assistance from staff with transfers, which was last reviewed/revised on date of 2/16/2017. R4's Impaired skin integrity Focus area was last reviewed/revised on 11/23/22, for interventions to monitor R4's incontinence. On 1/17/24 at 3:37PM, R4 was transferred from her position in a wheelchair into her bed, with assistance of two nursing staff, V14 and V15, both Certified Nurse Aides (CNA's), using a full mechanical lift. R4's was laid flat on her back in bed and R4's left pant leg was up, leaving R4's left lower ankle exposed, and revealing dark black dried streaks. V14 and V15 washed their hands, and placed on clean gloves. V14 was on R4's on left side of bed and V15 on R4's right side of bed. They removed R4's pants and soiled incontinent brief. R4 was heavily soiled with black, thick bowel movement from her front perineum area, inner lateral thighs, and streaks of black stool were down her inner left thigh to her ankle, and in between her toes. V14 and V15 positioned R4 to her left side, as V14 cleansed R4's perianal area. During R4's cleansing, V14 had stool on her gloves, folded the wet wash cloth, and continued to clean R4's buttock. V14 changed her soiled gloves, put on clean gloves, and placed R4 on her back to clean R4's front side. At this time, V14 and V15 stated they needed more wash cloths to clean R4. V15 changed her gloves, washed her hands, and left the room to get more clean wash cloths, and V15 re-entered the room. During this time, V14 and V15 discussed who was now dirty and who was clean to complete R4's incontinent bowel care. V14 then cleansed R4's front perineum area. R4 was heavily soiled with bowel movement from her perineum. V14 continued to use a clean wash cloth, folded cloth, and continued to cleanse R4's inner labia folds were not cleansed, only partially. R4 was then positioned to her right side, and V15 stated to V14, Am I clean or dirty now? V15 then cleaned R4's left side of perianal area and placed on a clean incontinent brief. R4 again rolled over to her left side, V14 and V15 fastened the incontinent brief. V14 then wiped the black dried stool from R4's inner left leg and between toes. On 1/17/24 at 4:05PM, both V14 and V15 stated they knew they did not do R4's incontinent care correctly. They both stated they came on thier shift at 2:00PM, and were immediately involved caring for another resident that was heavily incontinent of bowel movement, and they are the only two CNA's to attend to these resident on this hall on the evening shift. The facility's' policy and procedure, entitled, Hand Washing, dated, 9/4/2020, documented, this facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with contaminate substance, and continues to document the following: when hands are visibley dirty or soiled with body fluids, after removing gloves, hand 145769 Page 12 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0880 hygiene is always the final step after removing and disposing of personal protective equipment. Level of Harm - Minimal harm or potential for actual harm 5. R18's Care Plan, dated 7/26/2024, documented R18 has an actual pressure ulcer to her sacrum, right and left buttocks, and requires assistance with turning and repositioning. Residents Affected - Some R18's Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact and has 3 stage four pressure ulcers. R18's, Culture Report of sacrum, right and left buttock, dated 10/29/2023, documented R18 has Methicillin-resistant Staphylococcus aureus (MRSA). R18's, Progress Notes, dated 1/15/2024, documented R18 remains on isolation precautions for MRSA of the wounds to buttocks and sacrum. On 1/16/2024 at 10:30 AM, there was a Contact Precautions sign outside R18's room. At this time, V12, Certified Nursing Assistant (CNA) was observed assisting R18 with repositioning in bed. R18's bed linens were visibly soiled with a moderate amount of serosanguinous (clear/yellow) drainage. R18 had 3 open areas of skin on her backside. V12 did not have a Personal Protective Equipment (PPE) gown on. On 1/17/2024 at 2:14 PM, V7, Licensed Practical Nurse (LPN), stated R18 was on isolation for an infection of her wounds. V7 continued to state staff should be wearing a gown while providing direct care to R18. On 1/18/2024 at 1:31 PM, V1, Administrator, stated R18 is on contact precautions for MRSA of her wounds and she would expect staff to wear a gown and gloves while providing direct care, such as turning and repositioning, especially when there is drainage present. The Facility's Transmission Based Precautions Policy, dated 3/22/2023, documents, Purpose: To provide staff guidelines for transmission-based precautions to protect resident and themselves while providing cares. Policy: Transmission based precautions are initiated when a resident develops signs and symptoms of a transmission able infection, arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Responsibility: It is the responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. It further documents when a resident is on contact precautions, Staff are to wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 2. R9's admission Profile, print date of 1/22/4, documents R9 was admitted on [DATE], with diagnoses of Unspecified Fracture of Third Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Displaced Fracture of greater Trochanter of Left Femur, subsequent encounter for closed fracture with routine healing, and Chronic Obstructive Pulmonary Disease. On 1/17/2024 at 9:21 AM, V17, CNA, and V18, CNA, provided incontinent care to R9. R9 was incontinent of urine and feces. V17 and V18 washed their hands and applied gloves. V17 then cleansed urine and feces from R9's peri area. V17 and V18 rolled R9 onto her right side exposing R9's bottom. V17 then cleansed urine and feces from R9's bottom. V17 then, using the same urine and feces soiled gloves, placed R9's clean undergarment beneath R9 and manipulated R9's clothing and gloves, with the same urine and feces soiled gloves. 3. R14's face sheet, dated 1/18/24, documented R14 was admitted to the 145769 Page 13 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with diagnoses of Alzheimer's disease, dementia, osteoporosis, major depressive disorder, and macular degeneration. R14's MDS (Minimum Data Set), dated 1/9/24, documented R14 is severely cognitively impaired. On 1/16/24 at 9:10 AM, V9, CNA, entered R14's room and assisted R14 to the restroom. V9 donned gloves, without the benefit of hand hygiene, and then assisted R14 onto the toilet. V9 removed R14's clothing and disposable brief. V9 changed gloves, without the benefit of hand hygiene, and assisted V9 with perineal hygiene. V9 then placed a new disposable brief on R14 and dressed R14. V9 removed the gloves and donned new gloves, no hand hygiene performed. V9 then assisted R14 into bed. V9 removed the gloves and did not perform hand hygiene before leaving the room or after leaving R14's room. V9 then returned to the dementia unit dining room and assisted other residents. 4. R33's face sheet, dated 1/18/24, documented R33 was admitted to the facility on [DATE], with diagnoses of dementia, Alzheimer's disease, atherosclerosis, congestive heart failure, chronic kidney disease, and osteoarthritis. R33's MDS, dated [DATE], documented R33 is severely cognitively impaired. R33's care plan, dated 11/26/22, documented R33 requires extensive assist with all ADLS (activities of daily living). On 1/16/24 at 9:40 AM, V9, CNA, and V10, CNA, entered R33's room with a mechanical lift. V9 and V10 donned gloves without the benefit of hand hygiene. V9 and V10 transferred R33 onto the bed with the mechanical lift. V9 and V10 repositioned R33 and checked R33's disposable brief for incontinence. R33 was not incontinent at this time. V9 and V10 removed their gloves and left R33's room. V9 and V10 did not perform hand hygiene. On 1/22/24 at 8:31 AM, V1, Administrator. stated she would expect the CNA's to be completing hand hygiene before and after resident care, and before and after changing gloves. 145769 Page 14 of 15 145769 01/23/2024 Hallmark Hc of Carlinville 826 North High Carlinville, IL 62626

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 43 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 1/16/24 at 10:30 AM, 1 of these two-bed resident's rooms, measures 72 square feet. The resident residing in this room is R24. On 1/16/24 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 R19, R23, R31 and R32. On 1/16/24 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 R5, R11, R17, R18, R25, R26, R28, R37, R32, and R38. On 1/16/24 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, R6, R7, R8, R9, R10, R12, R13, R14, R15, R16, R21, R22, R23, R27, R29, R30, R32, R33, R34, R35, R36, R141, R142, and R143. On 1/18/24 at 9:45 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 1/17/24, documents there are 43 residents residing in the facility. 145769 Page 15 of 15