Hallmark HC of Carlinville

In the surveyor’s words

From the most serious findings on record at Hallmark HC of Carlinville, in the surveyor’s own words.

• Actual harm, isolatedF697Feb 26, 2025

  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. 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. […]

• Actual harm, isolatedF755Feb 26, 2025

  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. […]

• Actual harm, isolatedF684Jan 23, 2024

  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. 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. […]

• Actual harm, isolatedF697Mar 31, 2022

  Based on interview, observation, and record review, the facility failed to obtain and administer prescribed pain medications as ordered for 1 of 5 residents (R2) reviewed for pain management in the sample of 5. This failure resulted in R2, a newly admitted resident with post-surgical repair of a fractured leg with an Open Reduction Internal Fixation (ORIF) device, not receiving her pain medication, being in excruciating pain for over 48 hours to the point of attempting to go back to the hospital for pain control. Findings include: R2's Discharge Orders from the hospital, dated 3/26/22, documents medications to take after discharge, including [MEDICATION(S)]-Acetaminophen 5-325 mg every six hours for pain. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF925Apr 7, 2025

  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. 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. […]