Inspection Results » Hallmark Manor

Health Inspection on September 18, 2018 ^[1]

1. Isolated: Immediate jeopardy to the resident health or safety

   • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Corrected 2018-11-01)

2. Isolated: Actual harm that is not immediate jeopardy

   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-11-01)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-11-01)
   • Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Corrected 2018-11-01)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-11-01)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-11-01)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-01)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-11-01)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-11-01)
   • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2018-11-01)
   • Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (Corrected 2018-11-01)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2018-11-01)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-11-01)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-11-01)
   • Implement a program that monitors antibiotic use. (Corrected 2018-11-01)
   • Provide activities to meet all resident's needs. (Corrected 2018-11-01)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-11-01)
   • Provide appropriate foot care. (Corrected 2018-11-01)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-11-01)
   • Provide for the safe, appropriate administration of IV fluids for a resident when needed. (Corrected 2018-11-01)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-11-01)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-11-01)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-11-01)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-11-01)
   • Respond appropriately to all alleged violations. (Corrected 2018-11-01)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-11-01)
   • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-11-01)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-11-01)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-11-01)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-11-01)
   • Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (Corrected 2018-11-01)
   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2018-11-01)
   • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (Corrected 2018-11-01)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-11-01)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2018-11-01)
   • Assess the resident when there is a significant change in condition (Corrected 2018-11-01)
   • Provide or obtain dental services for each resident. (Corrected 2018-11-01)
   • Plan the resident's discharge to meet the resident's goals and needs. (Corrected 2018-11-01)
   • Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (Corrected 2018-11-01)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-11-01)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-11-01)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-11-01)
   • Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (Corrected 2018-11-01)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-11-01)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-11-01)
   • Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (Corrected 2018-11-01)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-11-01)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-11-01)
   • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (Corrected 2018-11-01)
   • Ensure that residents are fully informed and understand their health status, care and treatments. (Corrected 2018-11-01)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-01)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2018-11-01)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2018-11-01)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-11-01)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-11-01)