The Hallmark

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Residents #3, #20 and #36) and 2 of 2 (LVN A and LVN B) staff observed during medication administration. The facility failed to ensure staff Clarified any order that is incomplete, illegible, or presents any other concerns, prior to administering the medication for Resident #3, Resident #20 and Resident #36 on 03/18/2026. The failure could place residents at risk of receiving less than optimal results from their medication regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinent care. The facility failed to ensure Resident #1's catheter bag was not maintained below the bladder. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored and prepared under sanitary conditions, in one of one kitchen that serviced residents, in that: - Food was found open or without labels, - The high-temp dishwasher was not reaching a temperature of 180F and chlorine levels were not being tested to ensure proper sanitation of dishes and utensils. This failure could affect residents and place them at risk of food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess each resident's status for 2 of 4 residents (Resident #13 and Resident #15) reviewed for assessment accuracy. - The facility failed to accurately assess and document Resident #13's visual impairment requiring the use of glasses. - The facility failed to accurately assess and document Resident #15's use of continuous oxygen and visual impairment requiring the use of glasses. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care.

Inspectors wroteBased on observation, interview and record review the facility failed to deliver appropriate treatment and services to prevent urinary tract infections for 1 (Resident #3) of 1 resident s reviewed for appropriate services and treatment to prevent urinary tract infections. The facility failed to ensure Resident #3 's urinary catheter bag was not left on the floor. The facility failed put a date on Resident #3's urinary catheter bag. The facility failed to change out Resident #3's urinary catheter according to physician orders 10/15/2023 and 11/15/2023. These failure could affect residents placing them at risk of not receiving appropriate treatment and services from facility staff.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 residents (Resident#8) reviewed for pharmaceutical services. - The facility failed to administer medication to Resident #8 as ordered by applying Lidocaine 4 % patches to the resident's right knee and hip instead of Lidocaine 4% gel on multiple occasions between 11/15/23 at 11/29/23. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 24 % based on 8 errors out of 33 opportunities, which involved 3 of 6 residents (Resident #9 and Resident #13) reviewed for medication errors. - LVN D failed to administer medications as ordered to Resident #17 by pouring dry powder medication into the resident's G-tube immediately after a bolus feed of enteral formula. - LVN D failed to administer medications to Resident #17 as ordered by administered 20 mg of Amlodipine instead of 10 mgs. - LVN D failed to administer medication to Resident #8 as ordered by applying Lidocaine 4 % patches to the resident's right knee and hip instead of Lidocaine 4% gel. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a change in condition and a need to alter treatment significantly for 1 of 5 residents (Resident #121) reviewed for notification of changes. - The facility failed to notify the physician of Resident #121's red, swollen and tender right thumb identified on 11/30/23. This failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering. Findings Include: Record review of Resident #121's Face Sheet dated 11/30/23 revealed, a 77-yer-old male who admitted to the facility on [DATE] with diagnoses which included: high cholesterol, depression, hypertension and dementia. [...]

Inspectors wroteBased on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents (Resident #15) reviewed for care plans. -The facility failed to ensure Resident #15's comprehensive care plan addressed the residents use of glasses. This failure could place residents at risk of not having their needs met, decreased quality of life or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the residents choices 1 of 4 residents (Resident #121) reviewed for quality of care. -The facility failed to identify and take action on bruising Resident #121's upper left arm and swelling and pain on his right thumb. This failure could place residents at risk of delayed identification/treatment of injuries, worsening of injuries, pain and infection. Findings Include: Record review of Resident #121's Face Sheet dated 11/30/23 revealed, a 77-yer-old male who admitted to the facility on [DATE] with diagnoses which included: high cholesterol, depression, hypertension and dementia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 residents (Resident #17) reviewed for gastrostomy tube management. - LVN D failed to administer medications as ordered to Resident #17 by pouring dry powder medication into the resident's G-tube immediately after a bolus feed of enteral formula resulting in the resident stating she felt like she was going to explode. This failure could place residents at risk for adverse reactions, pain and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 out of 1 medication carts ( Nursing Cart ) reviewed for medication storage. - The facility failed to ensure the Nursing Cart did not contain Insulin Lispro for Resident #121 with no open date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: Record review of Resident #121's Face Sheet dated [DATE] revealed, a 77-yer-old male who admitted to the facility on [DATE] with diagnoses which included: high cholesterol, depression, hypertension, dementia and diabetes. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain diagnostic services as ordered by a physician for 1 of 2 residents (CR #20) reviewed for lab services, in that: - RN C failed to obtain stat labs for CR #20 as ordered by a physician. - This failure could place residents at risk of not receiving adequate medical care in a timely manner.