Hallmark Manor

In the surveyor’s words

From the most serious findings on record at Hallmark Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 27, 2022

  Based on observation, interview, and record review the facility failed to initiate Basic Life Support, which included rapid defibrillation and early CPR (Cardio-Pulmonary Resuscitation), when Resident 1 experienced a change in condition that required an immediate staff response to address a medical emergency. This failure increased the likelihood of unsuccessful CPR and resulted in Resident 1's death. An Immediate Jeopardy was called on [DATE] and removed on [DATE] when staff were trained, mock drills conducted, and staff records were updated with documentation of current staff CPR cards. Findings included . […]

• Actual harm, isolatedF684May 28, 2026

  Based 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. […]

• Actual harm, isolatedF686Jun 12, 2024

  Based 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. […]

• Actual harm, isolatedF689Mar 29, 2022

  Based on interview and record review the facility failed to provide adequate supervision, confirm planned fall interventions were implemented, functional, and effective to prevent falls for one (Resident 1) of four residents reviewed for accidents. These failures of the facility resulted in harm to Resident 1 and placed the other residents at risk for injury. Findings included . The Annual Minimum Data Set (MDS - an assessment tool), dated 12/16/2021, showed Resident 1 had medically complex conditions and Alzheimer's dementia, was cognitively intact (BIMS score of 13), with no behaviors. According to this MDS the resident was independent, with set up only for transfers, walking in room, toileting, was steady moving on and off the toilet, and used a walker. […]

• No harm, potential for more than minimal, widespreadF801Aug 19, 2024

  Based 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. Findings included . Review of the (undated) staff list showed Staff C (Dietary Manager) was employed by the facility on 08/07/2024. In an interview on 08/19/2024 at 9:48 AM, Staff A (Administrator) stated Staff C was required to have the ServSafe Manager Certification (verifies that a manager or person-in-charge has sufficient food safety knowledge to protect the public from foodborne illness) before being hired. […]