A list of the most recent deficiencies for Hallmark Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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. | Health | 2022-11-08 | 2022-12-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-08 | 2022-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-08 | 2022-12-20 | N |
| 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. | Health | 2022-11-08 | 2022-12-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-08 | 2022-12-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-08 | 2022-12-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-08 | 2022-12-20 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-11-08 | 2022-12-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-08 | 2022-12-20 | N |
| 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 necessary and PRN use is limited. | Health | 2022-11-08 | 2022-12-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-08 | 2022-12-20 | N |
| 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. | Health | 2022-11-08 | 2022-12-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-08 | 2022-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-08 | 2022-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-08 | 2022-12-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-08 | 2022-12-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-08 | 2022-12-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Establish methods for sharing information. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-31 | 2022-12-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-06 | 2022-06-30 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-27 | 2022-05-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-29 | 2022-04-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-28 | 2021-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-12-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-07 | 2019-12-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-07 | 2019-12-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-07 | 2019-12-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-07 | 2019-12-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-07 | 2019-12-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-07 | 2019-12-21 | N |
| 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. | Health | 2019-11-07 | 2019-12-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-07 | 2019-12-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-07 | 2019-12-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-07 | 2019-12-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-07 | 2019-12-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-07 | 2019-12-21 | N |
| 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 necessary and PRN use is limited. | Health | 2019-11-07 | 2019-12-21 | N |
| 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. | Health | 2019-11-07 | 2019-12-21 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-07 | 2019-12-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-07 | 2019-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-07 | 2019-12-21 | N |
| 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. | Health | 2019-11-07 | 2019-12-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-07 | 2019-12-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-11-07 | 2019-12-21 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-11-04 | 2019-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-04 | 2019-11-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-11-04 | 2019-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-04 | 2019-11-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-04 | 2019-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-04 | 2019-11-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-04 | 2019-11-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-04 | 2019-11-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-09-18 | 2018-11-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-09-18 | 2018-11-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-18 | 2018-11-01 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-18 | 2018-11-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-09-18 | 2018-11-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-18 | 2018-11-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-09-18 | 2018-11-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-09-18 | 2018-11-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-18 | 2018-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-18 | 2018-11-01 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-18 | 2018-11-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide appropriate foot care. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-18 | 2018-11-01 | N |
| 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 necessary and PRN use is limited. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-09-18 | 2018-11-01 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-18 | 2018-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-18 | 2018-11-01 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-18 | 2018-11-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-18 | 2018-11-01 | N |
| 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. | Health | 2018-09-18 | 2018-11-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-18 | 2018-11-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-09-18 | 2018-11-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-18 | 2018-11-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-09-18 | 2018-11-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-09-12 | 2018-10-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-09-12 | 2018-10-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-12 | 2018-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-12 | 2018-10-16 | N |
