Hallmark Healthcare Center

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide sanitary meal service when two kitchen staff failed to don [put on] appropriate facial hair covers for food preparation. This failure had the potential to affect 79 residents receiving dietary services from the facility.

Inspectors wroteBased on record review and interview, the facility failed to act promptly and to provide documented responses to recurring grievances related to call light response times that were expressed during resident council meetings for 10 of 13 months of meeting minutes reviewed. (June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, February 2026, and March 2026)

Inspectors wroteBased on a review of facility policy, observation, and interview, the facility failed to adhere to infection control guidelines. Specifically, clean linens were improperly stored in the soiled linen room and the laundry room was unclean, increasing the risk of cross-contamination. Findings Include: Review of the facility policy titled, Laundry dated 03/2006, states, All Linens . 1. Linens are to be handled in a safe manner to prevent contamination of the linen, the personnel and the environment . 6. Clean and soiled linen never comes in contact with each other . Housekeeping of Laundry facility: 1. The laundry facilities is to be kept clean and debris free. During an observation and interview on 03/24/25 at 11:15 AM, clean laundry (pillows, containers of clothes and other clean items) were being stored in the soiled room. [...]

Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to maintain equipment in safe operating condition. Specifically, 1 of the 2 washing machines in the laundry room was leaking water and chemicals from the rear of the machine. Findings Include: Review of the facility policy titled, Clinical Equipment Management last revised December 12, 2016, states, Inspections and maintenance will comply with all governing agencies and equipment manufacturer's recommendations in order to maintain safe operating conditions . prior to the use of all machines in the department, it will be the responsibility of the operator or provider of service to be certain that the machine is in good operational condition. [...]

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure expired and out dated medications and biological's were removed and not in use with residents' current medications and biological's, from 3 of 3 medication carts and 1 of 2 treatment carts.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure Resident (R)57 was clean, dressed, and free from facial hair, for 1 of 1 resident reviewed for respect and dignity.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to refer Resident (R)20 for a Preadmission Screening and Resident Review (PASARR) Level II, after the resident received a new diagnosis of a severe mental illness and/or experienced a significant change in status assessment related to their mental illness, for 1 of 2 residents, (Resident (R)20), reviewed for PASARR. Findings Include: Review of the facility policy titled, PASARR Documentation Policy last revised June 9, 2023, documented under PASARR Care Plan, 6 Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Review of R20's PASARR Level I Screening Form, dated 11/21/14, revealed the following diagnoses: [...]

Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to ensure placement of a feeding tube (abdominal) for Resident (R)45, before flushing with water and inserting oral medications into the tube, for 1 of 1 residents observed receiving medications via a feeding tube.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure medication irregularities were identified and reported to the physician for 2 of 5 residents reviewed, Resident (R)28 and R43. Specifically, R28's hydrocodone-acetaminophen (used to treat pain), venlafaxine (an antidepressant) and R43's olanzapine (an antipsychotic) were documented with the incorrect indication of use. Findings Include: Review of the facility policy titled, Medication Management Program last revised 05/05/23, states, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements . 2. [...]

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)1, while having an acute neurological change, was free from continued falls and injuries, for 1 of 3 residents reviewed.

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, dry storage, emergency storage and resident dietary rooms were properly labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Safety in Receiving and Storage, dated 08/01/2020, revealed, Food will be received and stored by methods to minimize contamination and bacterial growth. Receiving Guidelines .6. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. Dry Storage Guidelines .3. Containers holding food or food ingredients that are removed from their original packages such as cooking oils, flour, sugar, herbs and spices are identified with he common name of the food. Refrigerated Storage Guidelines .12. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to implement procedures and safeguards to reduce the potential growth and spread of Legionella. This failure had the potential to affect all resident in the facility.

Inspectors wroteBased on review of the facility policy, observation, record review, and interview, the facility failed to ensure that 1 (Resident (R)17) of 5 residents observed for resident rights was provided bathing preferences.

Inspectors wroteBased on review of facility policy, record reviews, and interviews the facility failed to provide a notice of transfer for hospitalization and the reasons for the transfer in writing or as soon as practicable to Resident (R)59 and R26, the Resident Representative and Ombudsman for 2 out of 2 residents.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to provide 2 out of 2 residents a copy of the bed hold policy in order to ensure that Resident (R)59 and R26 were aware of the bed hold policy and basic per diem rate.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for 1 (Resident (R)60) of 5 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to develop a comprehensive care plan for R60 to be on isolation precautions for the diagnosis of sabies.

Inspectors wroteBased on review of facility policy, observation, record review, and interview, the facility failed to ensure that 1 (Resident (R)17) of 5 residents reviewed for activities received activities that meet the intent and needs of each resident.

Inspectors wroteBased on review of facility policy, observation, record review, and interview, the facility failed to ensure Resident (R)55 was free from significant medication errors related to blood pressure (BP) medication administration for 1 of 5 residents reviewed for medication administration.