Hallmark Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 14, 2024

  Based 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. […]

• Actual harm, isolatedF550Oct 17, 2022

  Based 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. Findings include: I. Resident #17 A. Resident status Resident #17, age 78, was admitted on [DATE] and readmitted on [DATE]. […]

• Actual harm, isolatedF600Oct 17, 2022

  Based on interviews and record review, the facility failed to ensure one (#17) of two out of 40 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #17 did not suffer from emotional abuse 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. Findings include: I. Facility policy and procedure The Reporting Alleged Abuse policy and procedure, revised February 2017, was provided by the nursing home administrator on 10/10/22 at 8:30 a.m. It revealed, in pertinent part, This facility does not condone resident abuse and/or neglect by anyone. […]

• Actual harm, isolatedF686Oct 17, 2022

  Based 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. […]

• Actual harm, isolatedF692Oct 17, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Dietary interventions included snacks in the evening, two proteins during meals, 2% milk served with meals, and fortified foods when possible. Since admission on 2/10/22 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. […]