Hallmark Nursing Center

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nutrition and Dietary Deficiencies

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.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Pharmacy Service Deficiencies

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.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

A survey for Incident #CO36836 was conducted on 11/14/24. One deficiencies was cited. 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.Through a facility investigation, it was found that CNA #1 had not followed the resident individualized care plan accurately when she made the decision to provide care without a care partner to ensure proper technique for safety and appropriate bed mobility. The facility failed to ensure that Resident #1 received appropriate care per her comprehensive care plan for two staff members to assist with bed mobility and incontinent care which resulted in the resident falling out of bed and sustaining a hip fracture that required surgical intervention.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/14/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/28/24.I. Incident on 2/27/24CNA #1' s failure to follow the resident' s care plan to provide bed mobility with the assistance of two staff members led to the resident falling out of a high bed and sustaining a major injury (hip fracture). II. Facility plan of correctionInterviews and record review during the onsite investigation on 11/14/24 revealed the facility investigated this singular event and implemented corrective actions to prevent the recurrence of the incident.A. Immediate action to correct the deficient practice for Resident #1CNA #1 was suspended during the investigation and, upon her return on 3/1/24, CNA #1 was provided coaching and education on the facility' s policy that the resident' s care plan must be followed at all times. ..

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3 Room doors do not resist the passage of smoke room numbers 129,141 and 144.NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.NFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Freestanding cylinder were not properly chained or supported.NFPA 99- 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were identified during the survey and discussed with the Administrator and at the exit conference. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on February 27,2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) (V-A) construction with a crawl space. The original facility was constructed in 1985. This facility is licensed for 143 beds. The census on the date of the survey was 95. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic dry-pipe fire sprinkler system. This facility is classified as fully-sprinklered.The results of the survey were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with complaint #CO34412 was completed on 1/31/24 to 2/6/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 1/31/24 to 2/6/24. No deficiencies were cited. Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of six hallways.Specifically, the facility failed to:-Ensure residents' rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure clean technique was followed during wound care; and,-Ensure scissors were cleaned and disinfected according to standards of practice.Findings include:I. HousekeepingA. Professional referenceCenters for Disease Control. (5/4/23). Environment Cleaning Procedures. https://www.cdc.gov/hai/prevent/resource-limited/cl.. Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#45) out of 35 sample residents.Specifically, the facility failed to ensure that Resident #45 did not keep inhaler medications at the bedside.Findings include:I. Facility policy and procedureThe Self Administration of Medications policy and procedure, reviewed 11/28/16, was provided by the director of nursing (DON) on 2/5/24 at 4:39 p.m.It revealed in pertinent part,"Facility, in conjunction with the Interdisciplinary Care Team (IDT), should assess and determine, with respect to each resident, whether self administration of medications is safe and clinically appropriate, based on the resident' s functionality and health cond.. Based on record review and interviews, the facility failed to ensure treatment and services being provided met professional standards of quality for one (#12) of five residents reviewed for unnecessary medications out of 35 sample residents.Specifically, the facility failed to ensure that Resident #12 was administered the correct dose of insulin according to the physician ordered parameters.Findings include:I. Facility policy and proceduresThe Administration of Medications policy, revised 5/6/22, was provided by the director of nursing (DON) on 2/5/24 at 11:53 a.m. The policy revealed, "The facility would ensure medications were administered safely/appropriately per physician order, to address residents' diagnoses and signs and symptoms."Nursing staff were to check the MAR (medication administratio..

A complaint survey, prompted by #CO33739 was conducted on 10/5/23. One deficiency was cited. Based on interviews, observations and record review, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure resident food was palatable in temperature.Findings include:I. Professional referencesThe Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control."II. Facility policy and procedureThe Food Temperature Control policy, revised December 2021, was provided by the nursing home administrator (NHA) on 10/5/23. It revealed in pertinent part, "1. Food temperatures are checked at the compilation of the cooking process and before being placed on the serving line; if issues are identified, they are corrected, or the food is discarded. 2. Food temperatures are recorded prior to meal service on the Food Temperature Record Log. 3. If the food temperatures are unsatisfactory, the problem areas are corrected before serving the food items. 4. Hot foods are held at a minimum of 135 F or per state requirements.5. Cold foods are held at or below 41 F or per state requirements."III. Residents interviewsThree alert and oriented residents were interviewed on 10/5/23 between 11:34 a.m. and 3:30 p.m. Resident #1 stated that she ate in her room and the food was warm to cold when it arrived. Resident #3 stated that she frequently ate in her room and the food was frequently delayed and always arrived at the semi-warm temperature. Resident #5 stated he ate in his room and the food was delivered to him in semi warm to completely cold temperatures. He said the scrambled eggs in the morning were so cold like they were held in the refrigerator. IV. ObservationsDinner observations were co..