Hallmark Care Center

Inspectors wroteBased on clinical record reviews and staff interview, the facility failed to ensure residents were provided with education regarding the risks and benefits of psychotropic medications 4 of 5 residents reviewed for unnecessary medications (Resident #8, #18, #33, #38) . Additionally, the facility failed to offer alternative treatment options prior to the administration of the medications. The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to accurately code resident falls with major injury, medications, smoking, and restraints on the Minimum Data Set (MDS) Assessment for 5 of 15 reviewed (Resident #8, #13, #18, #28 and #31). The facility identified a census of 42 residents.

Inspectors wroteBased on a review of records, staff interviews, and facility policy, the facility failed to provide education and obtain informed consent for 4 of 4 residents regarding eligibility for influenza vaccination (Resident #7, #12, #18, and #24) and 3 of 3 residents for pneumococcal vaccination (Resident #7, #18, and #24). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, staff interview, and instructions of CMS form 10123-NOMNC, and 10055-SNF ABN, the facility failed to ensure an accurate and timely Notice of Medicare Non-Coverage (NOMNC) was provided and failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 1 of 3 residents reviewed for Beneficiary Notification (Resident #50). The facility reported a census of 42 residents.

Inspectors wroteBased on record review, staff and resident interviews, and policy review, the facility failed to maintain documentation of the information sent to the hospital to ensure that continuity of care and resident needs were maintained during the transfer process for 4 of 4 hospitalizations reviewed (Residents #2 and #6). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, Pre-admission Screening and Resident Review (PASRR), and resident and staff interviews, the facility failed to ensure a resident's mental health diagnosis and medications were accurately reported to the designated state agency for 1 of 3 residents diagnosed with Post Traumatic Stress Disorder (PTSD) (Resident #38) and failed to implement PASRR level II recommendations into the care plan for 2 of 3 residents (Residents #6 and #18). The facility reported a census of 42 residents.

Inspectors wroteBased on record review, staff and resident interviews, and policy review, the facility failed to implement interventions into the care plans for 2 of 2 residents following their return from hospitalizations (Residents #2 and #6). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, document review and staff interview the facility failed to follow physician orders to obtain daily weights for 1 of 1 resident sampled on daily weights (Resident #5). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, staff interview, CMS 2567 review, and QAPI (Quality Assurance Performance Improvement) Plan review, the facility failed to implement effective quality assurance processes to address Pre-admission Screening and Resident Review (PASRR) deficiencies, resulting in F644 being cited in 2025 as well as the current survey. The facility reported a census of 42 residents.

Inspectors wroteBased on document review, policy review, and staff interview the facility failed to ensure the Infection Preventionist attended the Quality Assurance and Performance Improvement (QAPI) quarterly meetings. The facility identified a census of 42 residents.

Inspectors wroteBased on a review of records, staff interviews, and facility policy, the facility failed to provide education and obtain informed consent for 2 of 5 residents regarding eligibility for COVID-19 vaccination (Resident #7 and #12). The facility reported a census of 42 residents.

Inspectors wroteBased on electronic health record review, Pre-admission Screening and Resident Review (PASRR) review, resident interview, staff interview, and policy review the facility failed to ensure a resident's mental health diagnoses and medications were accurately reported to the designated state agency for 1 of 3 residents diagnosed with PTSD (Post Traumatic Stress Disorder) (Resident #17). The facility reported a census of 38 residents.

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy review, the facility failed to ensure interventions for pain management provided resident with effective pain relief following a fall with injury to right wrist for 1 of 3 resident reviewed for pain management (Resident #8). The facility reported a census of 38 residents.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review the facility failed to account for a resident's experiences, preferences, and potential triggers that might cause re-traumatization for 1 of 3 residents diagnosed with PTSD (Post Traumatic Stress Disorder) (Resident #17). The facility reported a census of 38 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility policy review, the facility failed to provide bed hold notice to resident or resident representative prior to transferring 2 of 3 residents to the hospital (Resident #35 and Resident #27). The facility reported a census of 38 residents.

Inspectors wroteBased on MDS (Minimum Data Set) review, resident census data, the Resident Assessment Instrument (RAI) manual, staff interview, and policy review the facility failed to submit a discharge MDS for 1 of 1 residents reviewed (Resident #25). The facility reported a census of 38 residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure food items covered, dated, and stored to prevent possible cross-contamination. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, staff interview, and state designated authority direction for Preadmission Screening and Resident Review (PASRR) the facility failed to complete a follow-up PASRR screening for one out of one resident reviewed in the current sample who had a change in mental health status (Resident #17). The facility reported a census of 40 residents.