Hallmark Nursing Center

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with accepted professional standards in two of six medication carts. Specifically, the facility failed:-Ensure insulin Lantus (insulin) and NovoLog (insulin) pens were labeled with open dates;-Ensure expired medications were removed from the medication cart;-Ensure injectable medications were not stored with a needle attached; and-Ensure medications were stored by administration route.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development of transmission of disease and infection on two of two units. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequently touched areas (door handles, call lights, bed remote);-Ensure mop pads were changed after mopping the bathroom; and,-Ensure areas were cleaned from cleanest to dirtiest.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the residents' environment for two (#21 and #50) of three residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure Resident #21 and Resident #50's call lights were within reach when the residents were in their room.

Inspectors wroteBased on record review and interviews, the facility failed to provide the appropriate services to maintain ability to carry out ADLs for one (#6) of two residents out of 39 sample residents. Specifically, the facility failed to provide Resident #6 with nursing restorative therapy as recommended by physical therapy.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain effective pest control program for one (#50) of five residents reviewed out of 39 sample residents. Specifically, the facility failed to maintain pest free environment in Resident #50`s room.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards out of three sample residents remained free from accident hazards. On 2/27/24, just before 2:00 p.m. certified nurse aide (CNA) #1 was providing care to Resident #1. The resident was rolled on her side during the care and the resident slid off the side of the bed, fell to the floor and sustained a left hip fracture. The resident was sent to the hospital for treatment and underwent surgical repair of the left hip fracture. Through a facility investigation, it was found that CNA #1 had not followed the resident individualized care plan accurately when she made the decision to provide care without a care partner to ensure proper technique for safety and appropriate bed mobility. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure treatment and services being provided met professional standards of quality for one (#12) of five residents reviewed for unnecessary medications out of 35 sample residents. Specifically, the facility failed to ensure that Resident #12 was administered the correct dose of insulin according to the physician ordered parameters.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#45) out of 35 sample residents. Specifically, the facility failed to ensure that Resident #45 did not keep inhaler medications at the bedside.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of six hallways. Specifically, the facility failed to: -Ensure residents' rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure clean technique was followed during wound care; and, -Ensure scissors were cleaned and disinfected according to standards of practice.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure resident food was palatable in temperature.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#17) of two out of 40 sample residents was treated with dignity and respect and cared for in an environment that promoted her quality of life. Specifically, the facility failed to ensure Resident #17 did not suffer from emotional distress by registered nurse (RN) #4. The facility failed to provide Resident #17 an environment free to share her concerns without fear of humiliation, retaliation or intimidation. The facility's failure caused continued emotional distress experienced by the Resident #17.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide the necessary treatment and services to prevent the development of pressure injuries for one (#42) of two residents reviewed for pressure injury out of 40 sample residents. Resident #42 was identified by the facility as a high risk for developing pressure injuries upon his admission to the facility. On 9/13/22, the resident developed a pressure injury to the right trochanter (hip). The facility failed to ensure an initial assessment of the pressure injury was completed upon the residents admission, The physician was not notified timely and a treatment order was not put into place until 9/26/22; 13 days after the pressure injury was identified. A treatment note dated 9/27/22, by the wound physician, documented the resident had a stage 3 facility acquired pressure injury to her right hip. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one (#36) of four residents reviewed for nutrition out of 40 sample residents received the care and services necessary to meet their nutritional needs to maintain their highest level of physical well being. Resident #36 was admitted on [DATE] with diagnoses including depression, congestive heart failure, and hypertension. Dietary interventions included snacks in the evening, two proteins during meals, 2% milk served with meals, and fortified foods when possible. Since admission on [DATE] it was documented that Resident #36 was losing weight with variable meal intakes. A nutritional supplement was added on 3/23/22 and discontinued on 4/28/22 due to the resident's preference. [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure two (#42 and #20) of three residents reviewed for activities of daily living of 40 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to: -Ensure that Resident #42 received incontinence care timely; and, -Ensure that Resident #42 and #20 received repositioning timely.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure menus were followed to meet the residents' nutritional needs on two of two units. Specifically, the facility failed to follow the menu. Menu items were omitted without substitutions being made of the same nutritional value.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#76 and #17) of three out of 40 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to: -Respond timely to a grievance filed by Resident #76. The resident had a certified nurse aide (CNA) #3 help with the completion of a grievance form. CNA #3 placed the grievance form in her personal bag and placed it in her car instead of turning the grievance form into facility management. CNA #3 left the grievance form in her car until she returned to work six days later, and seven days after the incident, when she gave the grievance form to the social service director (SSD); and, -Respond to a grievance for Resident #17, when she reported her sunglasses missing to staff.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide an ongoing program to support residents in their chosen activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#84 and #71) of four out of 40 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #84 and Resident #71.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure two (#18 and #42) of six residents reviewed with limited mobility reviewed for range of motion (ROM) received appropriate services, equipment, and assistance to maintain maximal mobility and services to prevent further decrease in ROM, out of 40 sample residents reviewed. Specifically, the facility failed to provide: -Resident #18 contracture management services to maintain or prevent decline to his range of motion for contractures in his left elbow, left wrist, and left hand. He was not being offered or provided items for his left hand for his contracture. (carrots or rolled towel). He had not been evaluated for contracture devices since 2020. -Resident #42 had contracture management services for contractures to his right upper extremity.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (#71 and #39) out of two residents reviewed for respiratory care out of 40 sample residents. Specifically, the facility failed to: -Ensure Resident #71 had a physician's order in place for oxygen therapy; and, -Ensure oxygen was administered according to physician orders for Resident #39.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#13) of five out of 40 sample residents were free from unnecessary drugs as possible. Specifically, the facility failed to ensure a pharmacy recommendation was followed up on for Resident #13.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in one out of three medication carts. Specifically, the facility failed to ensure medications were labeled with open dates.

Inspectors wroteBased on observations and interviews, the facility failed to ensure beverages were provided and within reach for the resident for two (#58 and #41) of two residents reviewed for hydration out of 40 sample residents. Specifically, the facility failed to: -Ensure Resident #58 had access to a sufficient amount of water throughout the day; and, -Ensure Resident #41's water pitcher was within reach.