Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hallmark Hc Of Carlinville during CMS and state inspections, most recent first.
Multiple areas of the facility, including medication and laundry rooms as well as several resident rooms and closets, were found to have mouse droppings, with several residents and staff reporting ongoing mouse sightings and infestations. The exterminator serviced only common areas and offices, not resident rooms, and the administrator was unaware of the issue. Glue traps and bait boxes were used reactively, but the facility did not maintain an effective pest control program as required by policy.
A resident with hyperkalemia and dementia did not receive timely pain management due to a delay in pharmacy delivery and a malfunctioning medication dispensing machine. The resident exhibited signs of discomfort, including labored breathing and twitching, but was only given Tylenol until the prescribed medications were delivered the following morning.
A resident under hospice care did not receive prescribed morphine for nine hours due to a delay in pharmacy delivery and issues with the facility's medication dispensing machine. The resident, experiencing pain and shortness of breath, was eventually administered the medication the following morning, alleviating their discomfort.
The facility failed to dispose of expired medications, affecting all 37 residents. Expired medications were found in the Unit Med Cart, Main Floor Med Cart, and Medication Room, including Fiber Laxative, Atropine, Mucus Relief, and Influenza Vaccines. Staff interviews revealed confusion about responsibility for checking expiration dates, contrary to the facility's policy requiring outdated drugs to be returned or destroyed.
The facility failed to store food at the required temperature and did not discard expired food, risking foodborne illness for all 37 residents. The freezer was above the required temperature, containing thawed and mushy food items. Interviews revealed the freezer malfunctioned, and food was moved to a sister facility, but some items remained improperly stored. The facility's policy lacked guidance on the duration for keeping leftovers and opened beverages.
The facility failed to provide written explanations for hospital transfers for three residents, including those with Dementia and Alzheimer's. Despite being transferred due to falls and critical conditions, the notices lacked documentation of reasons. Interviews with an LPN and the DON confirmed the absence of written notices, and the facility's policy did not address this requirement.
A resident with severe cognitive impairment and a Stage 3 pressure ulcer did not receive the prescribed treatment due to conflicting orders and missing iodoform packing strip. The facility's policy requires adherence to treatment orders, which was not followed, as acknowledged by the DON and Wound Nurse Practitioner.
The facility failed to clean soiled surfaces for two residents during care. A resident was transferred from a wheelchair without sanitizing it after incontinence, and another was seated in a wheelchair with a soiled napkin and dried food. The administrator acknowledged the oversight but had not provided a policy. One resident had a diagnosis of Dementia.
The facility failed to provide the required 80 square feet of floor space per resident in all resident bedrooms, affecting all 37 residents. None of the 25 two-bed rooms meet the minimum space requirement. The administrator acknowledged the deficiency, stating that all rooms are below the required size and mentioned having a room waiver for this issue.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of mouse droppings in various areas including the medication room, laundry room, and several resident rooms and closets. Residents and staff reported ongoing sightings of mice, with one resident stating that mice were caught in their room and another describing a mouse running across their chest while sleeping. Mouse droppings were also found on residents' personal clothing and in common areas. The facility's pest control policy requires maintaining a pest-free environment, but the presence of droppings and live mice indicates this was not achieved. Interviews with staff revealed that glue traps and other measures were used reactively, and the exterminator reported only servicing common areas and offices, not resident rooms, due to residents often being asleep. The exterminator was aware of a mouse problem and had recently added bait boxes outside, but there was no indication that a comprehensive or proactive approach was in place. The administrator was unaware of the mouse problem, and the maintenance director had recently quit, further contributing to the lack of an effective pest control program.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R34, who was admitted with diagnoses of hyperkalemia and dementia. The resident had physician orders for Lorazepam and Morphine Sulfate to be administered as needed for restlessness, agitation, pain, and shortness of breath. However, these medications were not available from the pharmacy in a timely manner. On the night of February 24, 2025, the resident exhibited labored breathing, gurgling, and occasional moaning, indicating discomfort. Despite these symptoms, the prescribed medications were not delivered, and the facility was unable to access them from the backup medication dispensing machine due to a malfunction. The resident was only administered Tylenol for pain relief, which was documented as a pain level of 4 on a 0-10 scale. The following morning, the resident continued to show signs of discomfort, such as twitching and open-mouth breathing. The facility staff, including a Licensed Practical Nurse and the Administrator, confirmed that the medications were not available until later that morning due to pharmacy delivery issues and a malfunctioning medication dispensing machine. This delay in medication administration resulted in the resident not receiving timely pain relief, contrary to the facility's policy on pain management.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide necessary pain medication to a resident, identified as R34, who was under hospice care and experiencing pain and shortness of breath. R34 was admitted with diagnoses of hyperkalemia and dementia. A physician's order was in place for Morphine Sulfate to be administered every two hours as needed for pain and shortness of breath. However, the medication was not available for nine hours, resulting in the resident experiencing undue pain. The hospice notes indicated that the resident had labored breathing, gurgling sounds, and occasional moaning, with a prescription for morphine and Ativan not yet delivered from the pharmacy. The delay in medication delivery was due to the facility's regular pharmacy not delivering the medication on time, and issues with accessing the facility's medication dispensing machine. The LPN and another staff member attempted to retrieve the medication from the dispensing machine but were unsuccessful due to a malfunction, which was later fixed. The facility's administrator acknowledged the issue, noting that the pharmacy had specific cutoff times for new orders, and the medication was eventually delivered the following morning. The resident received the morphine at 9:35 AM, which alleviated their pain.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to dispose of expired stock medications, which could potentially affect all 37 residents. During a review of the Unit Med Cart, several expired medications were found, including Fiber Laxative caplets and Atropine ophthalmic solution. Additionally, the Main Floor Med Cart contained expired Mucus Relief, Acidophilus, Vitamin C, and Cetirizine. In the Medication Room, multiple bottles of Mucus Relief, Benadryl, Tylenol Suppositories, and a significant number of expired Influenza Vaccines were discovered. These expired medications were stock meds available for use by all residents. Interviews with staff revealed a lack of clarity regarding responsibility for checking medication expiration dates. A Licensed Practical Nurse was unsure who was responsible, while the Director of Nursing stated that everyone should check expirations when administering medications. The facility's Medication Storage policy requires that outdated drugs be returned to the pharmacy or destroyed, and medications should be administered before their expiration date. However, this policy was not adhered to, leading to the presence of expired medications in the facility.
Improper Food Storage and Expired Food Handling
Penalty
Summary
The facility failed to store food at the required temperature and did not discard expired food, which could potentially lead to foodborne illness affecting all 37 residents. During an inspection, it was observed that the stand-up freezer had a temperature of 33 degrees Fahrenheit, which is above the required 0 degrees Fahrenheit as per the facility's policy. The freezer contained various thawed and mushy food items, including vegetables, chicken patties, sausage patties, hamburger patties, garlic bread, and liquid popsicles and ice cream. Additionally, the refrigerator contained a precooked ham and several beverage cartons with dates indicating they were past their safe consumption period. Interviews with the facility's cook, dietary aide, and dietary manager revealed that the freezer had stopped functioning properly at the beginning of the week, and most of the frozen food had been moved to a sister facility. However, some food items were still being stored in the malfunctioning freezer. The dietary manager admitted to bringing over just enough food for the weekend and later discarding the thawed items. The administrator confirmed that a new freezer had been purchased. The facility's policy did not adequately address the duration for which leftovers and opened beverage cartons should be kept, contributing to the deficiency.
Failure to Provide Written Explanation for Hospital Transfers
Penalty
Summary
The facility failed to provide residents with a written explanation for their transfer to the hospital, affecting three residents reviewed for hospitalization. Resident 28, who was admitted with a diagnosis of Dementia, was transported to a local hospital due to a fall as per the on-call doctor's orders. However, the Notice of Transfer or Discharge did not document the reason for the transfer. Similarly, Resident 29, with diagnoses including Severe Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus, and Dementia, was sent to the emergency room due to a fall and complaints of hip and lower back pain, but the notice also lacked documentation of the reason for the hospital transfer. Resident 34, diagnosed with Alzheimer's, was transferred to an acute care hospital due to a critical potassium level, yet the Notice of Transfer or Discharge failed to document the reason for the transfer. Interviews with a Licensed Practical Nurse and the Director of Nurses revealed that residents were not provided with written notices explaining the reasons for their hospital transfers. Additionally, the facility's Bed Hold Notification policy did not address the requirement to provide a written explanation for hospital transfers.
Failure to Provide Prescribed Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide the prescribed pressure ulcer treatment for a resident with severe cognitive impairment and a Stage 3 pressure ulcer. The resident, who also has severe protein-calorie malnutrition, Type 2 Diabetes Mellitus, and Dementia, was admitted with a documented pressure ulcer on the sacrum. The treatment administration records indicated two different treatment orders for the pressure ulcer, both of which were signed off on the night shift. However, during an observation, it was noted that the iodoform packing strip, which was part of the prescribed treatment, was missing from the wound's tunneling. The Director of Nurses acknowledged the presence of conflicting wound care orders and the absence of the iodoform packing strip during the dressing change. The Wound Nurse Practitioner confirmed that the treatment orders should have been followed as written, although it was unclear if the oversight caused harm due to the resident's multiple health issues. The facility's policy on pressure ulcer prevention and treatment emphasizes the responsibility of the charge nurse or designee to provide treatments as ordered, which was not adhered to in this case.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents during routine care. On February 23, 2025, during incontinent care, two CNAs transferred a resident, R21, from a wheelchair to a bed. The resident was wearing sweatpants with a visible wet area due to incontinence of a large amount of loose watery stool. After providing care, the CNAs did not sanitize the resident's wheelchair. Another incident involved a resident, R31, who was transferred from a bed to a wheelchair that had a soiled napkin and a large spot of dried food on the seat. The CNAs did not clean the seat before seating the resident. The facility administrator acknowledged the oversight but had not provided a relevant policy by February 26, 2025. R31 was admitted with a diagnosis of Dementia.
Facility Fails to Meet Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident in all resident bedrooms, affecting all 37 residents living in the facility. The facility consists of 25 resident rooms, each designed to accommodate two residents, but none of these rooms meet the minimum space requirement. This deficiency was confirmed through observation, interviews, and record reviews. On the specified date, measurements of all resident rooms revealed that they were less than 80 square feet per resident. The facility's administrator acknowledged the deficiency, stating that all rooms are below the required size and mentioned having a room waiver for this issue. The maintenance director also confirmed the lack of compliance with the space requirement, noting that all rooms are less than 80 square feet per resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carlinville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Health & Rehab Center | 0.4 mi | ★★★★★ | 9 | 1 |
| Carlinville Rehab & Hcc | 0.4 mi | ★★★★★ | 3 | 0 |
| Gillespie Health & Rehab Ctr | 12.9 mi | ★★★★★ | 3 | 0 |
| Litchfield Health & Rehab Center | 14.6 mi | ★★★★★ | 0 | 0 |
| Avenues At Litchfield | 15 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.