Hallmark Hc of Carlinville

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide residents with a written explanation as to why they are being transferred to the hospital for 3 of 3 residents (R28, R29, R34) reviewed for hospitalization in the sample of 43.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for a neurological change in condition for one of 1 residents (R39) reviewed for notification in the sample of 46. Findings Include: R39's Electronic Medical Record documents diagnoses included: Chronic Myeloid Leukemia, BCR/ABL - Positive, not having achieved remission [The presence of the BCR-ABL1 abnormality confirms the clinical diagnosis of CML, a type of ALL, and rarely acute myeloid leukemia (AML)], chronic diastolic (congestive) heart failure, hypertension, and heart failure. R39's admission Minimum Data Set (MDS), dated [DATE], documents she was alert. R39's Nurses Note, dated 12/10/2022 at 3:22 PM, documents CNA (Certified Nursing Assistant) picked up a blue pill from the resident's room laying on her bed. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.