F 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 maintain an effective pest control program.
This has the potential to affect all 38 residents living in the facility.
Residents Affected - Many
Findings include:
1. On 4/7/25 at 11:45 AM, the medication room was observed; mouse droppings were found around the
baseboards.
2. On 4/7/25 at 11:50 AM, the laundry room was observed; mouse droppings were found around the
baseboards in the dirty room.
3. R2's Face Sheet, print date of 4/7/25, documents R2 was admitted on [DATE] and has a diagnosis of
Diabetes.
R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact.
On 4/7/25 at 8:46 AM, R2 stated, I did see mice last week. They caught two in the room and 1 in the
bathroom.
On 4/7/25 at 8:50 AM, under R2's window, mouse droppings are observed.
4. R3's Face sheet, print date of 4/7/25, documents R3 was admitted on [DATE] and has diagnoses of a
History of Heart Attack and Dependence on Renal Dialysis.
R3's General Note, dated 4/2/2025, documents, Resident arrived by hospital transport in w/c (wheelchair)
accompanied by wife and daughter, pleasant. Alert and oriented.
On 4/7/25 at 8:35 AM, R3 stated, I saw 2 (mice) on the floor and one jumped up and ran across my chest
while I was sleeping. I did let someone know. I don't remember their name. They put a mouse trap in here.
On 4/7/25 at 8:38 AM, R3's room was observed; mouse droppings were in the closest and in the bathroom.
5. R4's Face Sheet, print date of 4/7/25, documents R4 was admitted on [DATE] and has a diagnosis of
Bipolar Disorder.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145769
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
(X3) DATE SURVEY
COMPLETED
A. Building
04/07/2025
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 0925
R4's MDS, dated [DATE], documents R4 is cognitively intact.
Level of Harm - Minimal harm
or potential for actual harm
On 4/7/25 at 8:50 AM, mouse droppings were observed in R4's closet. R4's room and bathroom had no
mouse traps in it.
Residents Affected - Many
On 4/7/25 at 9:05 AM, R4 stated, I did have mice in the room, but they came in and put traps down.
6. R5's Face Sheet, print date of 4/7/25, documents R5 was admitted on [DATE], and has a diagnosis of
Dementia.
R5's MDS, dated [DATE], documents R5 is severely cognitively impaired.
On 4/7/25 at 8:59 AM, R5 stated she does see mice on the floor of her room.
On 4/7/25 at 9:00 AM, R5's closet has mouse droppings in it. In the closet, there is a laundry basket with 3
items of clothing. The clothing has mouse droppings on them.
On 4/7/25 at 8:20 AM, V1, Administrator, stated, Today is my first day. I am unsure about a mouse problem.
The Maintenance Director recently quit.
On 4/7/25 at 8:53 AM, V3, Housekeeping stated,About a week ago, I saw a mouse in the laundry room. We
put glue traps out.
On 4/7/25 at 8:56 AM, V4, Housekeeping, stated, I have noticed mice. We keep putting traps down.
On 4/7/25, V6, Certified Nurse Aide, stated, Mice have been around or a couple of months. We were putting
out traps and we caught quite a few, but then we stopped catching them, so we switched to glue traps.
On 4/7/25 at 9:22 AM, V9, Exterminator, stated he visits the facility 2 times a month. One visit is for the
outside and the other is for the inside. When I do the inside, I do the kitchen, common areas, and the
offices. I don't go into residents' rooms because usually they are asleep. I was aware of a mouse problem
and I put out 4 new bait boxes outside and looked for holes to seal up. I do not remember if the facility let
me know they had an active problem or not. I will walk around with (V1) today when I come. At 1:04 PM, V9
stated he is adding 5 more bait boxes to the outside, and will come back next week to check on the
progress and effectiveness of the new bait boxes.
The policy Pest Control, dated 7/1/24, documents, It is the policy of this faciilty to maintain an effective pest
ontrol program so that it remains free of pests and rodents.
The Long Term Care Facility Application for Medicare and Medicaid, dated 4/7/25, documents the facility
has 38 residents residing in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145769
If continuation sheet
Page 2 of 2
