Health inspection·February 26, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm On 2/24/25 at 10:45 AM, V2, Director of Nurses, stated she did not believe the residents are given anything in writing as to why they are going to the hospital. The policy Bed Hold Notification, undated, fails to address the need to provide a written explanation as to why a resident is being sent to the hospital to the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 2 of 12 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 02/26/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide the prescribed pressure ulcer treatment for 1 of 2 residents (R29) reviewed for pressure ulcers in the sample of 43. Residents Affected - Few Findings include: R29's Face Sheet, print date of 2/24/25, documents R29 was admitted on [DATE] and has diagnoses of Severe Protein - Calorie malnutrition, Type 2 Diabetes Mellitus, and Dementia. R29's Minimum Data Set, dated [DATE], documents R29 is severely cognitively impaired and has 1 Stage 3 pressure ulcer. R29's Treatment Administration Record, start date of 1/11/25 with a discontinue date of 2/25/25, documents, Silver sulfadiazine External Cream 1 % (Silver Sulfadiazine) Apply to Sacrum topically every night shift for wound care Cleanse area with WC (wound cleanser), pat dry, apply SSD (Silver Sulfadiazine), Hydrogel, collagen, calcium alginate, cover with ABD (abdominal pad) pad, secure with retention tape daily and PRN (as needed). This treatment was signed off on night shift on 2/23/25. R29's Treatment Administration Record, start date of 1/31/25, documents, Sacrum: cleanse with wound cleanser, apply calcium alginate, collagen particles, SSD (Silver Sulfadiazine) and iodoform packing strip and apply ABD daily and PRN until healed. This treatment was signed off on night shift on 2/23/25. The Wound Assessment Report, dated 2/20/25, documents R29 has a Sacrum Pressure Ulcer Stage 3 measuring 2.0 cm x 0.70 cm x 0.50 cm undermining from 9 o'clock to 3' o'clock 2 cm. On 2/24/25 at 2:16 PM, V2, Director of Nurses, removed the sacrum dressing dated 2/24/25. The dressing had brown yellowish drainage. There was no iodoform packing strip in the tunneling of the wound. V2 cleansed the pressure ulcer with wound cleanser, measured the pressure ulcer at 3 centimeters (cm) x 0.7 cm. V2 did not measure the depth. The pressure ulcer tunnels up toward 12 o'clock. On 2/24/25 at 3:10 PM, V2 stated there was no iodoform packing strip in the pressure ulcer tunnel. V2 acknowledged the two conflicting wound orders in place for R29. On 2/25/25 at 3:01 PM, V21, Wound Nurse Practitioner, stated, They should have been following the orders the way they were written. It is hard to say if it caused him harm because he has so many other contributing factors. The policy Pressure ulcer Prevention, Identification, & Treatment, dated 10/16/23, documents, It is the responsibility of the charge Nurse / designee to care for pressure areas, and provide treatments as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 3 of 12 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 02/26/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on interview, observation, and record review, the facility failed to provide pain relief for 1 of 1 resident (R34) reviewed for pain in the sample of 43. This failure resulted in R34 not having R34's pain controlled. Residents Affected - Few Findings include: R34's Face Sheet, print date of 2/25/25, documents R34 was admitted in 10/3/23 and has diagnoses of Hyperkalemia and Dementia. R34's Physician Order, dated 2/24/2025 at1:15 PM, documents, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 2 hours as needed for restlessness and agitation. R34's Physician Order, dated 2/24/2025 at 1:15 PM, documents, Morphine Sulfate (Concentrate) Solution 20 MG/ML (milliliter) Give 0.25 milliliter by mouth every 2 hours as needed for pain and shortness of breath. R34's Hospice Notes, dated 2/24/2025 11:30 PM, documents, Resident cont (continued) with hospice care. Respirations labored with gurgling noted. Breath sounds wet, not moving secretions out. Skin cool & clammy to the touch. Afebrile. Occasional moan noted. SPO2 (oxygen saturation) 94% 4L (liters) O2 (oxygen) via mask. Residents eyes open & resting in bed with HOB (head of bed) elevated. PRN (as needed) morphine et (and) ativan not yet delivered from pharm (pharmacy). Unable to pull from backup. Hospice notified. NOR (new order received) to start Hyoscyamine (used for secretions) 0.125 SL (sublingual) q (every) 4 hrs (hours) PRN et 650 mg (milligram) acetaminophen rectal suppositories q 4 PRN. Hospice to f/u (follow up) on Rx (prescription) that was sent last week to pharmscripts to get delivered asap (as soon as possible). R34's MAR documents R34 received Tylenol on 2/24/25 at 11:20 PM for pain of a 4 on a 0 - 10 scale. No other doses of Tylenol given. On 2/25/5 at 9:08 AM, R34 is lying in bed, eyes closed and open mouth breathing. R34 has a nonrebreather oxygen mask on. R34 is twitching his left arm and hand. R34 has twitching of his bilateral feet. On 2/25/25 at 9:11 AM, V10, Licensed Practical Nurse, stated, (R34's) Morphine and Ativan are not in from pharmacy yet. They got a prescription sent into the local pharmacy that just opened up. (Pharmacy) is our regular pharmacy but they haven't delivered it yet. I checked on (R34) earlier I think he is comfortable. He does have the Tylenol and Hyoscyamine if he needs it. R34's MAR documents R34 received Morphine on 2/25/25 at 9:35 AM for pain of a 4 on a 0 - 10 scale. On 2/25/25 at 12:12 PM, R34 is lying in his bed, eyes closed, and open mouth breathing. R34 has a nonrebreather oxygen mask on. R34 is lying still, no twitching observed. On 2/25/25 at 12:14 PM, V10, stated, The facility was able to get the morphine and ativan. I gave it to him about 20 minutes after I talked to you this morning. He is more comfortable now. On 2/25/25 at 2:49 PM, V1, Administrator, stated, We sent the order to pharmacy. They have cut off (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 4 of 12 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 02/26/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few times. At night when we didn't have it, the nurse tried to get into (facility medication dispensing machine) to get the medication, and she was unable to. (V2) even came up and she was not able to get into it either. There was a problem with the (medication dispensing machine) which is fixed now. We called again this morning and the pharmacy was able to get it to us. We did end up getting the medication from our pharmacy and not the local one because our pharmacy was on the way before the in town pharmacy opened. On 2/25/25 at 2:52 PM, V2, stated she did come up the night before and try to get the Morphine and Ativan out of the (medication dispensing machine), but she was unable to. The policy Management of Pain, dated 5/16/22, documents, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 5 of 12 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 02/26/2025 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few Based on interview, observation, and record review, the facility failed to provide pain medication for 1 of 1 resident (R34) reviewed for pain in the sample of 43. This failure resulted in R34 not having Morphine available for 9 hours, which resulting in undue pain. Findings include: R34's Face Sheet, print date of 2/25/25, documents R34 was admitted in 10/3/23 and has diagnoses of Hyperkalemia and Dementia. R34's Physician Order, dated 2/24/2025 at 1:15 PM, documents, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 2 hours as needed for restlessness and agitation. R34's Physician Order, dated 2/24/2025 at 1:15 PM, documents, Morphine Sulfate (Concentrate) Solution 20 MG/ML (milliliter) Give 0.25 milliliter by mouth every 2 hours as needed for pain and shortness of breath. R34's Hospice Notes, dated 2/24/2025 11:30 PM, documents, Resident cont (continued) with hospice care. Respirations labored with gurgling noted. Breath sounds wet, not moving secretions out. Skin cool & clammy to the touch. Afebrile. Occasional moan noted. SPO2 (oxygen saturation) 94% 4L (liters) O2 (oxygen) via mask. Residents eyes open & resting in bed with HOB (head of bed) elevated. PRN (as needed) morphine et (and) ativan not yet delivered from pharm (pharmacy). Unable to pull from backup. Hospice notified. NOR (new order received) to start Hyoscyamine (used for secretions) 0.125 SL (sublingual) q (every) 4 hrs (hours) PRN et 650 mg (milligram) acetaminophen rectal suppositories q 4 PRN. Hospice to f/u (follow up) on Rx (prescription) that was sent last week to (pharmacy) to get delivered asap (as soon as possible). On 2/25/25 at 9:11 AM, V10, Licensed Practical Nurse, stated, (R34's) Morphine and Ativan are not in from pharmacy yet. They got a prescription sent into the local pharmacy that just opened up. (Pharmacy) is our regular pharmacy but they haven't delivered it yet. I checked on (R34) earlier; I think he is comfortable. He does have the Tylenol and Hyoscyamine if he needs it. R34's Medication Administration Record (MAR) documents R34 received Morphine on 2/25/25 at 9:35 AM for pain of a 4 on a 0 - 10 scale. On 2/25/25 at 12:14 PM, V10, stated, The facility was able to get the morphine and ativan. I gave it to him about 20 minutes after I talked to you this morning. He is more comfortable now. On 2/25/25 at 2:49 PM, V1, Administrator, stated, We sent the order to pharmacy. They have cut off times. At night when we didn't have it, the nurse tried to get into (facility medication dispensing machine) to get the medication and she was unable to. (V2) even came up and she was not able to get into it either. There was a problem with the (medication dispensing machine) which is fixed now. We called again this morning and the pharmacy was able to get it to us. We did end up getting the medication from our pharmacy and not the local one, because our pharmacy was on the way before the in-town pharmacy opened. On 2/25/25 at 2:52 PM, V2, stated she did come up the night before and try to get the Morphine and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 6 of 12 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 02/26/2025 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 0755 Ativan out of the (medication dispensing machine), but she was unable to. Level of Harm - Actual harm (Pharmacy) Illinois Pharmacy Information, undated, documents, for new orders on Monday - Friday the cutoff Time is 11:00 AM and 11:00 PM. Medication Ordering Reminders. If a medication is needed before the next delivery will arrive, call the pharmacy to request a STAT delivery. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 7 of 12 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 02/26/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility to dispose of expired stock medications used by all residents. This failure has the potential to affect all 37 residents in the facility. The Findings Include: On [DATE] at 8:40 AM, the Unit Med Cart was reviewed with V4, Registered Nurse (RN), with the following medications expired: Fiber Laxative 625 MG (milligram) caplets that expired on 12/2024. A resident (R28) had a bottle of Atropine 1% ophthalmic solution that expired on 1/2025. On [DATE] at 8:45 AM, the Main Floor Med Cart was reviewed with the following medications expired: Mucus Relief 400 MG expired on 12/2024, Acidophilus 200 million cells/dose expired on 11/2024, Vitamin C 500 MG expired on 11/2024, and Cetirizine 10 MG that expired on 1/2025. On [DATE] at 8:55 AM, the Medication Room reviewed with the following expirations: Mucus Relief 400 MG bottles with 300 caplets - three bottles total, and all had expired on 12/2024. Benadryl 12.5 MG 8 OZ (ounce) bottle expired on 1/2025. Tylenol Suppositories 650 MG expired on 10/2024. Influenza Vaccines, 2023-2024 formula, with 39 syringes expired on [DATE], 10 syringes that expired on [DATE], and Influenza Quadrivalent vaccination with 18 syringes that expired on [DATE]. On [DATE] at 9:15 AM, V4, stated, We had a clinic come in and provide all vaccinations to the residents and they brought their own vaccinations, so the facility did not use ours, that is why they are all expired. All the medications that were expired in the med cart, and the influenza vaccines, were stock meds and can be and are used by all residents when needed. On [DATE] at 8:20 AM, when asked who is responsible for checking expirations on medications, V10, Licensed Practical Nurse (LPN), stated I don't know, (V2, Director of Nursing) who is responsible for checking expirations on medications? On [DATE] at 8:22 AM, V2, Director of Nursing (DON), stated, Everyone is responsible for checking the expirations on medications. They really should be checking them when they have the bottle out to give that medication. The Facility's Medication Storage policy, dated [DATE], documents, The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 8 of 12 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 02/26/2025 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 0761 The Resident Census and Conditions of Residents, CMS 671, dated [DATE], documents the facility has 37 residents living in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 9 of 12 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 02/26/2025 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 interview, observation, and record review, the facility failed to store food at the needed temperature and discard expired food to prevent food borne illness. This failure has the potential to affect all 37 residents living in the facility. Findings include: On 2/23/25 at 8:21 AM, the stand up freeze had a temperature of 33 degrees. This freezer contained: large bag of carrots, bag of mix vegetables, and a bag of mixed onions and peppers that were thawed and mushy, a box of popsicles that were liquid, 16 precooked chicken patties that were thawed, 21 magic cup ice cream that were liquid, a large box of sausage patties that were completely thawed, a large box of hamburger patties that were partially thawed, 3 loaves of garlic bread that were thawed, and a box of multiple bags of whip cream that is liquid. The stand up refrigerator had a precooked ham that was dated 2/11, a carton of ready care thickened water dated 12/9, a carton of prune juice dated 11/4, and a carton of orange juice dated 2/14. On 2/23/25 at 8:25 AM, V15, Cook, stated the freezer stopped freezing at the beginning of the week and they were told they could keep using it as long as it stayed at 32 degrees or lower. Most of our frozen food is across town at our sister facility. We just bring over what we need for a few days. On 2/23/25 at 8:30 AM, V16, Dietary Aide, stated the beverage cartons are dated when they are opened. On 2/23/25 at 10:02 AM, V17, Dietary Manager, stated, The freezer has been out since Friday. We moved most of our product to (sister facility). Friday I brought over just enough food for the weekend. I have thrown all the food out now. Leftovers are only good for 4 days. I don't believe the ham was from 2/11; I think it was dated wrong. The date on the beverage cartons is when it came in not when it was opened. On 2/23/25 at 3:00 PM, V1, Administrator, stated, We went a bought a new freezer. The policy All time/ Temperature control for Safety ((TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code, dated 9/1/21, documents, Freezer temperatures will be maintained at a temperature of 0 F (Fahrenheit). This policy fails to address how long left overs and open cartons of beverages are to be kept. The Resident Census and Conditions of Residents, CMS 671, dated 2/23/25, documents the facility has 37 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 10 of 12 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 02/26/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to clean soiled surfaces for 2 of 8 residents (R21,R31) reviewed for infection control in the sample of 43. Residents Affected - Few Findings include: 1. On 2/23/2025 at 10:53AM during incontinent care, V5, Certified Nursing Assistant (CNA), and V9, CNA, transferred R21 from wheelchair to bed. R21 had dark blue sweat pants on that had visible wet area on seat of pants. R21was incontinent of a large amount of loose watery stool. After incontinent care provided to R21, V5 and V9 did not sanitize R21's wheelchair. On 2/25/2025 at 2:48PM V13, CNA, stated if during incontinent care a resident is soiled through clothing onto chair, the chair should be cleansed. 2. On 2/23/25 at 12:48 PM, V5 and V19, CNA, transferred R31 from the bed to the wheelchair. The wheelchair seat had a soiled napkin and a large spot of dried food in the seat. Neither CNA cleaned off the seat before sitting R31 down. On 2/25/25 at 2:50 PM, V1, Administrator, stated, The wheelchair should have been cleaned before they (R31) down. I will look for a policy. R31's Face Sheet, print date of 2/25/25, documents R31 was admitted on [DATE] with a diagnosis of Dementia. As of 2/26/2025 at 10:38 AM, no policy has been provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 11 of 12 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 02/26/2025 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 all resident bedrooms. This has the potential to affect all 37 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. The residents residing in these rooms are R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, 34, R35, R37, R38, and R40. Two rooms, rooms [ROOM NUMBERS], are currently being used as a dining room on the Dementia Unit. On 2/23/25 at 10:30 AM, all resident rooms measured, were less than 80 square foot per resident. On 2/23/25 at 11:00 AM, V1, Administrator, stated, All of our rooms are less than 80 square foot per resident. We have a room waiver for this. On 2/23/25 at 11:05 AM, V6, Maintenance Director, stated, I don't have a list of the rooms with their sizes, I just know they are all less than 80 square foot per resident. The facility's Resident Census and Conditions of Residents, CMS 671, dated 2/23/25, documents there are 37 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145769 If continuation sheet Page 12 of 12