Hallmark Manor

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a full assessment, monitor, notify the provider and take timely action for a latent injury and a significant change in pain experience for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 who reported a popping noise after receiving care from staff and acute pain, experienced harm with increasing pain when there was a delay in transfer to the hospital for evaluation where they were diagnosed with a right ankle fracture.

Inspectors wrote<Resident 35> Review of a 10/22/2024 nursing progress note showed Resident 35 was transferred to the hospital for complaints of abdominal pain, chest pain, and shortness of breath. Review of Resident 35's records on 05/13/2025 showed no documentation staff provided Resident 35 or their representative with a written transfer notice. There was no progress note or copy of the written transfer notice available in Resident 35's record. In an interview on 05/13/2025 at 11:12 AM, Staff B and Staff F reviewed Resident 35's record and stated staff did not document the written transfer notice was provided as required. Staff B stated it was their expectation staff provided the notice within at the time of the resident being transferred, and in emergencies, the notice should be provided within 24 hours, and a copy was expected to be in the resident's record. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure sharps and chemicals were stored safely for 2 units (South and North Units) and 2 storage rooms (Soiled Laundry Room & Central Supply Room) reviewed. This failure to ensure sharps and chemicals were secured placed residents at risk for exposure to sharps and chemicals, and other negative health outcomes.

Inspectors wroteBased on record review and interview, the facility failed to provide required liability notices for 1 of 3 residents (Resident 247) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage (NOMNC) before coverage for Medicare services ended for Resident 247 and discharged from the facility, placed the resident at risk for not fully understanding their Medicare benefits.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, clean, and homelike environment was provided to the residents. Failure to ensure resident rooms were personalized for 1 (South Wing) of 2 wings reviewed and maintain resident weight scales clean and free from rust for shower rooms on 2 (North and South Wing) of 2 wings reviewed, left residents at risk for a less than homelike environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days from the date of determination for 1 of 1 resident (Resident 92) reviewed for death. Failure to identify the need for a SCSA when Resident 92 had a decline in condition and started on Hospice/Palliative care services placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status for 1 of 3 residents (Resident 94) reviewed for closed records and 1 of 7 residents (Resident 1) reviewed for falls. This failure placed residents at risk for unidentified and/or unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (a process to determine what mental health services residents required after a Level 1 PASRR determined mental health services were necessary) were obtained for 5 (Residents 35, 80, 3, 5, & 71) of 9 residents whose PASRRs were reviewed. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on record review and interview the facility failed to ensure development of a Palliative care plan for 1 of 3 residents (Resident 92) reviewed for closed records. Failure to develop a Palliative care plan placed residents at risk of unmet care needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to facilitate quarterly care conferences for 3 of 3 residents (Resident 1, 50, & 64) reviewed for care conferences, and failed to ensure Care Plans (CP) were revised as required for 2 (Resident 71 and 88) of 2 residents reviewed for care planning. These failures placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: physician orders were obtained for bed rails and blood sugar parameters, clarify physician orders, and medications were administered within ordered parameters for 3 (Residents 80, 88, & 1) of 20 sample residents. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 (Residents 46, 61 & 62) of 7 residents who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate laboratory testing for 2 (Resident 80 & 88) of 5 residents reviewed for unnecessary medications, failed to report changes of condition for 2 (Residents 44 & 46) of 2 sampled residents, and failed to administer pain medications for 1 (Resident 65) of 1 sampled residents. These failures to ensure adequate testing to prevent unnecessary medication use, identify changes of condition, and administer pain medications placed residents at risk for the administration of unnecessary medications, discomfort from skin impairments and untreated pain, and other negative health outcomes.

Inspectors wrote<Resident 3> Continuous observation on 05/08/2025 at 12:11 PM showed staff bring Resident 3 their lunch tray to their room. Staff elevated Resident 3's head of bed to a sitting position, placed their lunch tray on the over the bed table in front of them, and then exited the room. The lunch tray had ground pork in gravy, potatoes, and green beans. Observation showed Resident 3 did not feed themselves. At 1:04 PM Staff BB (CNA) entered Resident 3's room to remove the lunch tray and Resident 3 stated they could not feed themselves. Staff BB asked Resident 3 if they wanted assistance and Resident 3 stated yes but the food was probably cold now. Staff BB stated it was still warm and asked if Resident 3 wanted a bite of green beans, the resident replied yes. Staff BB assisted Resident 3 with a bite of green beans and the resident stated yuck, it's cold. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure ongoing monitoring of bed rail use for 3 of 6 residents (Residents 5, 64, & 80) reviewed for accident hazards. This failure placed residents at risk for injury, entrapment, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to the resident records and that the recommendations were reviewed and acted upon for 2 (Resident 35 & 1) of 5 residents who were reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, risk for adverse side effects, and receiving medications without required pharmacist oversight.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 6 sampled residents (Resident 26) reviewed for unnecessary medications. Failure to evaluate the need for continued use of an antibiotic medication placed residents at risk for use of unnecessary medications and at risk for adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 4 medication carts (Medication Cart 300/400) and 2 of 4 halls (600 & 300 Hall) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance and palatable. Observations of meal trays and interviews with 5 (Residents 61, 46, 71, 145, & 29) sample residents and 4 supplemental (Residents 69, 45, 83, & 70) residents identified concerns about the taste and overall palatability of the meals served, and being offered alternate meals by the facility. Facility failure to ensure meals were palatable, appetizing in appearance, and alternate meals were offered by staff placed residents at risk for less than adequate nutritional intake and dissatisfaction with daily meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed infection control practices to help prevent the transmission of communicable diseases. The facility failed to ensure staff performed Hand Hygiene (HH) when providing personal care for 1 (Resident 50) and failed to follow an Enhanced Barrier Precaution (EBP) sign for 1 (Resident 50) who required EBP. These failures placed residents at risk for the development of contagious, communicable diseases, and an unclean environment.

Inspectors wroteBased on interview and record review the facility failed to ensure the person designated to serve as the Dietary Manager (Staff C) had the proper training and qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare and serve food to residents in accordance with professional standards for food service safety. The failure to check temperatures on foods served, prevent cross-contamination, label and date refrigerated foods after opening, throw out expired foods past three days of opening, prevent pests in food storage areas, clean kitchen vents that circulate air around foods, perform hand hygiene, and untimely service of meals placed all 92 residents at the facility at risk of foodborne illness, poor nutritional intake, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer/pressure injury (PU/PI) for 1 of 4 sampled residents (Resident 1). Resident 1 experienced harm when they developed an unstageable (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) wound to their right foot requiring hospital treatment and amputation.

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory services according to professional standards of practice for 8 of 10 Residents (Residents 1, 2, 3, 4, 5, 6, 7 & 8) reviewed for COVID-19 testing. The facility failed to obtain Physician Orders (PO) to conduct COVID-19 testing for 6 of 10 residents (Residents 1, 2, 3, 4, 5 & 6), and failed to document the results of the testing for 3 of 10 residents (Resident 6, 7 & 8). This failure increased the likelihood for the delayed identification/diagnosis of COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to respond to abuse allegations in a timely manner, for 2 of 3 sampled residents (Resident 1 & 8). In addition, the facility failed to ensure residents were protected to prevent further potential abuse or mistreatment when they allowed Staff E, Certified Nursing Assistant (CNA), to continue to work with residents after an allegation of abuse. Failure to recognize possible abuse, suspend the alleged perpetrator pending investigation, and immediately investigate allegations, placed the resident at risk for diminished quality of life, and continued possible abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 4 (Residents 25, 91, 8, & 68) of 5 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wrote<Resident 8> According to the 01/09/2024 admission MDS, Resident 8 readmitted to the facility from the hospital on [DATE] and had intact memory. The MDS showed Resident had diagnoses including respiratory failure, and dependence on oxygen. According to a 12/31/2023 progress note, Resident 8 transferred to the hospital with no new concerns with cognition noted at time of discharge. A second 12/31/2023 progress note showed no new concerns with mood noted at time of discharge. An 11/23/2023 progress note showed Resident 8 reported having shortness of breath . MD notified [,] ordered transfer resident to the hospital. In an interview on 03/06/2024 at 9:15 AM Resident 8 they were not offered a bed hold when they went to the hospital on [DATE] or 12/31/2023. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 6 of 27 medications for 3 of 5 residents (Resident 77, 16, 80) observed during medication pass resulted in a medication error rate of 22.22 %. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately store drugs and/or biologicals (medicine derived from natural sources) for 1 of 2 medication storage rooms, and 1 of 2 treatment carts reviewed for medication storage. These failures placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meals that accommodated resident food allergies and preferences for 5 (Resident 14, 8, 18, 56, & 245) of 7 sample residents reviewed for preferences. This failure placed residents at risk for weight loss, frustration, and a diminished quality if life.

Inspectors wroteBased on observation and interview the facility failed to store food under sanitary conditions for 1 of 1 kitchens. Failure to ensure food items in the dietary department were properly stored, labeled, and out-of-date foods were identified and discarded, placed residents at risk for consuming expired/spoiled foods and potential exposure to food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent placing residents at risk for facility acquired infections. The failure to ensure staff used appropriate Personal Protective Equipment (PPE) on 2 of 2 Units, and to ensure proper Hand Hygiene was performed on 2 of 2 units before and after care/contact placed residents at risk for facility-acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services in a manner that promoted resident dignity for 5 (Residents 38, 55, 25, 56, & 91) of 24 sample residents reviewed, and 1 of 2 assisted dining rooms. The failure to provide care with dignity placed residents at risk for frustration, unmet care needs, and a diminished sense self worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Significant Change Minimum Data Set (SCSA- an assessment tool) was completed as required for 1 (Resident 68) of 24 sampled residents reviewed. The failure to complete a Significant Change MDS timely left residents at risk for unassessed care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 (Residents 2, 18, 91, & 7) of 24 residents Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 1 of 6 residents (Resident 47) reviewed for PASRRs. This failure left residents at risk for risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CP) were revised as needed for 6 of 24 (Residents 14, 38, 8, 2, 91, & 35) sample residents reviewed. The failure to ensure CPs were updated to reflect current care needs left residents at risk for unmet care needs, inappropriate care, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were followed for 5 (Residents 16, 80, 25, 19, & 8) of 24 sample residents; POs were clarified as needed for 2 (Resident 19 & 68) of 24 sample residents; nurses signed only for tasks completed for 3 (Resident 2, 16, 80) of 24 sample residents; and adequate rationale was provided for a late onset mental health condition for 1 (Resident 38) of 5 residents reviewed for unnecessary medication. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure restorative nursing services were provided for 1 of 1 residents reviewed for rehab/restorative (Resident 90) and 2 supplementary residents (Residents 18 & 85). This failure left residents at risk for diminished Range of Motion (ROM), loss of function, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident supervision, thorough accident investigation to determine the cause of incidents, and implement interventions required to prevent injury for 2 of 11 (Resident 11, & 55) sampled residents reviewed for accidents and supervision. The facility's failed practice resulted in the continued risk of receiving injuries related to avoidable incidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided within professional standards of nursing for 2 of 4 sample residents (Residents 8 & 295) reviewed for respiratory care. The failure to ensure Oxygen (O2) tubing was replaced per facility policy, O2 tanks were replaced when empty, and O2 concentrators were set per the Physician's Order (PO) placed residents at risk for Shortness of Breath (SOB), respiratory distress, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received ongoing communication and collaboration with the Hemodialysis (HD- a process to remove blood waste) center for 1 of 1 (Resident 295) residents reviewed for dialysis. This failure to communicate and collaborate with the dialysis as required, placed dialysis residents at risk for adverse health outcomes, inadequate quality of care and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with dementia received the appropriate treatment and services for 1 of 1 (Resident 55) residents reviewed for dementia care. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered Care Plan (CP) prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance committee that met at least quarterly and included the required participants. This failure placed residents at risk for unmet care needs due to on going non-compliance with federal regulations and detracted from the interdisciplinary effectiveness of the nursing home Quality Assurance team.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) assessments accurately reflected residents' mental health conditions and/or a PASARR was completed for 5 (Resident 63, 66, 38, 12, & 24) of 7 residents reviewed. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided necessary assistance for 7 (Residents 22, 16, 8, 50, 38, 63, & 70) of 7 sample residents reviewed. Failure to provide assistance to residents who were dependent on staff for bathing placed residents at risk for unmet needs, poor hygiene, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide mobility and Range of Motion (ROM) treatment and services to increase, maintain, or prevent further decrease in mobility and ROM for 3 of 5 (Residents 63, 70 & 16) residents and 2 supplemental residents (Residents 25 & 379) reviewed for limited ROM. The failure to place residents on a Restorative Nursing Program (RNP) after completion of Physical Therapy (PT) or Occupational Therapy (OT), and implement RNP established by therapy placed residents at risk for functional decline, mobility, and loss of ROM.

Inspectors wroteBased on interview and record review the facility failed to have sufficient nursing staff to provide care and services as evidenced by seven resident interviews and ten staff interviews. The failure to ensure adequate Registered Nurse (RN) and Certified Nursing Assistant (CNA) staffing to maintain infection control standards related to COVID-19 (Coronavirus, a highly contagious infectious respiratory disease) and Tuberculosis (TB) screening, provide Restorative Nursing Programs (RNP), verify and maintain staff credentials and competency, ensure assistance with showers according to resident care plan and preferences, and timely call light response to resident needs, placed residents at risk for unmet care needs, decline in condition and negative outcomes.

Inspectors wroteBased on record review and interview the facility failed to obtain verification from the state survey registry to ensure Certified Nursing Assistants (CNA) met competency evaluation requirements before the staff's start date for 3 of 5 staff (Staff P, Q & CC) reviewed. The failure to ensure the competency of staff placed residents at risk of unmet care needs and abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement a system of medication records that ensures accurate reconciliation and accounting of all controlled medications for 4 of 5 inventory of controlled substance books reviewed from 2 of 4 medication carts (Hall 700 medication cart and Hall 400 medication cart). This failure placed residents at risk for misappropriation of property and drug diversion.

Inspectors wroteBased on interview and record review the facility failed to ensure 5 of 5 (Residents 9, 379, 24, 63, & 12) residents reviewed for unnecessary medications and 3 supplemental residents were free from unnecessary psychotropic medications (a drug that affects brain activities associated with mental processes and behavior). The facility failed to obtain informed consent prior to administering psychotropic medications (Residents 379, 9, 12, 24, & 63); identify and monitor target behaviors (Residents 379, 9 & 38); identify and implement non-medication, behavioral interventions prior to administering an antianxiety medication (Resident 379); [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent and contain the transmission of communicable diseases including Covid-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). The facility failed to ensure staff completed hand hygiene during medication administration for 3 of 3 residents (Resident 66, 72 and 19), conduct cleaning and sanitizing procedures for reusable medical equipment before, after, and in between resident use, and adhere to N95 fit testing requirements for 2 of 5 staff (Staff M and N). These failures placed residents, staff, and visitors at risk for the development and transmission of infections, including Covid-19.

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that implemented an antibiotic stewardship program, to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use, including the development of antibiotic resistance, for 5 (Residents 12, 71, 13, 49, & 8) of 6 residents reviewed who were treated with antibiotics. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of Antibiotics (ABO).

Inspectors wroteBased on observation, interview, and record review the facility failed to recognize and treat 1 of 3 residents (Resident 24) who were reviewed for pain management. Failure to implement identified interventions to alleviate pain, including administration of pain medication after conducting the scheduled pain assessment, resulted in Resident 24 experiencing daily episodes of untreated pain, and placed the resident at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure ongoing collaboration with the dialysis center for 1 (Resident 74) of 1 residents reviewed for hemodialysis (purifying the blood of a person whose kidneys were not functioning normally). Facility failure to establish an agreement with the dialysis center, collect run sheets (a document describing all the care provided at a dialysis session) and monitor weights, left the resident at risk for fluid overload (too much fluid in the body) and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent (%). Failure of 1 of 2 nurses (Staff W) to properly administer 7 of 25 medications for 1 of 4 residents (Resident 68) observed during medication pass resulted in a medication error rate of 28%. This failure placed the residents at risk for adverse side effects due to improper medication administration.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications and vaccines (a preparation that is used to stimulate the body's immune response against diseases) were disposed of timely, in accordance with currently accepted professional standards of practice for 1 of 2 medication rooms reviewed. Additionally, the facility failed to secure all medications in a locked storage area for 1 of 1 resident (Resident 39) during medication administration. These failures placed residents at risk for receiving compromised medications with decreased or no potency and inadvertent ingestion of unsecured medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccines were provided for 1 of 5 residents (Resident 63) and influenza vaccinations were provided for 1 of 5 residents (Resident 9) reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and influenza diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provided a safe environment to help prevent and contain the transmission of Covid-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). The facility failed to ensure staff completed the required Covid-19 vaccination verification for 2 of 2 contracted staff (Staff Z and AA). These failures placed residents, staff, and visitors at risk for the development and transmission of Covid-19 infection. [...]