F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to develop and implement a comprehensive person-centered
care plan for each resident that included measurable objectives and timeframes to meet a resident medical,
nursing, mental, and psychosocial needs for two (Resident#6 and Resident # 3) of six residents reviewed
for care plans.
The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #6
required psychotropic medication.
The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #3
required ADL (activity of daily living) care.
This failure could place residents at risk of receiving inadequate interventions not individualized to their
care needs.
Findings included:
Resident #6
Record review of Resident #6's face sheet revealed a [AGE] year-old male was admitted to the facility on
[DATE]. His diagnoses were dementia, major depressive disorder, hypertension, and atrial fibrillation.
Record review of Resident #6's quarterly MDS dated 0428/22 revealed BIMS of 13 indicating intact
cognition. Further review revealed the resident required total assistance with ADL with two persons assist. It
also triggered in CAA section that Resident #6 was on Psychotropic drug use and to care plan it.
Record review of Resident #6's care plan did not reveal he was on any psychotropic medication.
Record review of Resident #6's order summary report dated August 2022 revealed an order of Fluoxetine
HCI 20 mg, give on tablet by mouth one time a day for depression, and ordered on 05/13/22.
In an interview on 08/11/22 at 8:42 a.m., the MDS coordinator said she was responsible for creating a
comprehensive centered care plan, and it is due on the 21st day upon admission. She said resident #6's
psychotropic medication should be care planned, but she missed it. She stated it was necessary to care
plan the medication because the nurses use it when providing care for the resident. she
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
676423
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
said it is vital to have it in the care plan because the nurses use it to care for the resident. She said it might
affect the resident negatively because the nurses may not provide care adequately, which may affect the
resident's health.
Interview on 08/11/22 at 11:10 a.m., DON said the MDS coordinator was responsible for the patient's
comprehensive cantered care plan within 14 days of admission, and she was not aware Resident #6's
psychotropic medication was not care planned. She said nurses use a care plan when providing care for
the residents, and if it were not care planned, the nurses would not know the interventions that were put in
place, and it would affect the care provided for the resident, and they may not receive appropriate care.
Resident #3
Record review of Resident #3's face sheet reviewed a [AGE] year-old female was admitted to the facility on
04/18/ 22. Her diagnoses included cerebral infraction due to embolism of left middle cerebral artery,
hemiplegia, hypertension, chronic atrial fibrillation, and atherosclerotic heart disease.
Record review of Resident # 3's quarterly MDS dated [DATE] revealed BIMS of 00 indicating severe
impaired cognition. It further revealed resident required supervision with one person set up for toilet use
and personal hygiene. She also needed extensive assistance with bathing with one person assist. She is
also occasionally incontinent of bowel and bladder.
Record review of Resident #3's undated care plan did not reveal ADLs were care planed.
Record review and Interview on 09/11/22 at 8:45 a.m., MDS coordinator viewed Resident #3's MDS with
the surveyor, and MDS coordinator stated Resident #3's comprehensive care plan was not completed
because her ADL was not care planned. She said, it is what it is because she has other duties besides
creating care plans and MDS. She said when a care plan is not patient care centered and complete, the
resident may not get the care they need, which may affect the resident's wellbeing.
Interview on 09/11/22 at 11: 15 a.m., DON said a comprehensive centered care plan should be completed
within 14 days of admission. She also said ADL was an essential part of resident care and should be care
planned because the nurses used it to provide care for the resident and were unaware of the omission. In
addition, if ADL is not care planned, the resident may not get the required assistance, which may affect the
quality of care.
Record review of the facility undated care plan read in part . must develop a comprehensive care plan for
each resident that includes measurable objective to meet a resident's medical, nursing, mental and
psychosocial wellbeing .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure residents who need respiratory care
were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident
#15) reviewed for respiratory care.
Residents Affected - Few
The facility failed to follow the physician orders for Resident #15's oxygen administration.
This failure placed residents who received oxygen therapy at risk of respiratory complications.
Findings include:
Record review of Resident #15's face sheet revealed a [AGE] year-old female resident was admitted to the
facility on [DATE] and readmitted on [DATE]. her diagnoses were, diabetes mellitus, major depressive
disorder, anxiety disorder, and atherosclerotic heart disease.
Record review of Resident #15's quarterly MDS dated [DATE] revealed BIMS of 15 indicating intact
cognition. Further review revealed the resident required minimal assistance with ADL with one person
assist.
Record review of Resident #15's care plan dated 06/03/22 revealed the resident has episodes shortness of
breath related to congestion. It also read may have 02 at 3 liters per nasal cannula as needed. The date it
was initiated was 01/21/2020. Intervention: Monitor /document changes in orientation, increased
restlessness, anxiety, and air hunger.
Record review of Resident #15's order summary report for August 2022 read: May apply oxygen at 2L per
NC as needed for oxygen saturation less than 90%, order date 03/17/21.
Record review of Resident #15's progress notes dated from 08/02/22 through 08/09/22 revealed there was
no documentation that Resident #15 oxygen saturations was 90 % or less.
Record review of Resident #15 MAR for August 2022 revealed there was no section in the MAR for oxygen
monitoring.
Observation on 08/09/22 MA A said the oxygen was set at three liters on the concentrator. She said she
does not know how many liters the resident should be on. MA A said she was a medication aide and does
not change the setting on the concentrator. She said the nurse was the only person who could change the
setting.
Interview on 08/09/22 at 11:19 a.m., Resident #15 said she does not know how many liters of oxygen she
should be on. Additionally, Resident # 15 said she does not know when or how to change the oxygen
setting. Resident #15 said she could not tell the difference from 2 to 3 L.
Observation and interview on 08/09/22 at 12:11 p.m. RN B said the oxygen setting on Resident #15's
concentrator was on 3L. RN B said the aide checked Resident #15 oxygen saturation. She said she makes
rounds every two hours and makes rounds when she comes in at 6:45 a.m., but she did not check the O2
concentrator setting today. RN B said she had no reason for not checking the setting on the concentrator.
RN B said the resident was on oxygen at 2 to 3 liters, and it was continuous. She looked at
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
her MAR and stated the resident's order was for 2 liters PRN (as needed). She said the resident could have
adverse outcomes such as distress and do not feel like breathing, or it could affect her lungs. she said
oxygen is considered medication and could not be changed without a doctor's order. She said she did not
change the setting, which meant it was at that setting when she took over the shift. She said she was
trained on how to monitor oxygen. She said the aide checked her oxygen saturation this morning when she
checked her other vital signs, and it was at 96% and she had oxygen at the time.
Interview on 08/09/22 at 12:23 p.m., CNA A said the aides checked Resident #15 and other residents 02
while checking vital. During training, they are told to take the O2 sat and not to touch the concentrator. She
said she gives the vital signs to the medication aide and nurse as soon as she finished taking the vitals and
her oxygen saturation was 96% and she had oxygen on.
Interview on 08/10/22 at 2:43 p.m., Interim ADON said the CNAs does check O2 when they check all
residents' vital signs and give it to the nurse. She stated the nurse checked the resident's oxygen saturation
and setting on the concentrator Q shift (each shift). She said the nurse was not following the doctor by
giving Resident #15 oxygen when it is above the perimeter and should not increase the setting on the
concentrator. She said the nurse needs a doctor's order to change Resident #15's 02 setting on the
concentrator. She stated the DON monitors nurses to ensure they follow the doctor's order for oxygen. She
said if the resident oxygen was changed, either increased or decreased, it should reflect on the resident's
care plan. She said it was not indicated on the MAR because her oxygen saturation had not been 90% or
less.
Interview and record review on 08/11/22 at 8:10 a.m. LVN B said he worked with Resident #15 on Sunday
(08/07/22) and Monday (08/08/22) night. He did not change her oxygen setting from 2 liters to 3 liters, and
Resident #15 could not have changed it because it was behind her bed and could not reach the
concentrator. LVN B said the resident oxygen order was for 2 liters continuous, and the aides took the
resident oxygen saturation, including Resident #15, and documented it on the vital section in PCC. LVN B
reviewed Resident #15's physician and stated it should have been PRN (as needed) at 2 liters if her oxygen
saturation was less than 90%. He said oxygen is considered a medication and could not be changed
without a doctor's order. He further stated Resident #15 always wants the oxygen on all the time, but he
had not notified the doctor or documented Resident #15 wants to wear her oxygen on all the time. He said
he made rounds once to check the resident oxygen concentrator setting during his shift. He said
administrating oxygen to Resident #15 incorrectly could affect the resident's lungs negatively. He said he
had a skill check-off, which included oxygen administration, and the DON monitors the nurses to ensure
they are administering oxygen as ordered.
Interview on 08/11/22 at 11:00 a.m.; DON said the nurses checked 02 SATs for the resident on oxygen and
documented it on the MAR (medication administration record). She said the nurses should follow the
doctor's order while administering O2. She said oxygen is considered a medication. The nurses should get
an order before changing the setting on the concentrator and transcribe the order to PCC (point click care),
which should also reflect on the care plan. She said Resident #15 oxygen stated PRN; then it should be
administered PRN after checking the O2 sat. If the resident always wants to keep it on, the nurses must
notify the doctor and follow the doctor's instructions. If the oxygen was increased, the nurse should
document why it was increased, and the doctor was notified. DON said administering O2 was more than
needed; it could harm the resident lungs. She said she is responsible for checking on the nurses to make
sure they provide O2 per physician order. She said the nurses had skills checked off, including oxygen
administration.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Record review of the facility medication administration dated 3/2004 read in part . to assure the safety and
wellness of the resident's while they live in the healthcare center .
Record review of the facility oxygen administration dated 11/01/17 read in part . policy interpretation and
implementation #1 . verify physician order for oxygen administration .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon
observation and interview, drugs and biologicals used in the facility must be secured in locked
compartments, labeled in accordance with currently accepted professional principles, and included the
appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2
medication carts ( Nurse Medication Cart) and 1 medication room ( South Medication Room) reviewed for
drug labeling and storage.
- The facility failed to ensure a previously opened Insulin pen stored on Nurse Medication Cart had an open
date labeled on the pen to track expiration of insulin device.
- The facility failed to ensure the South Medication Room did not contain expired IV Medications.
These failures could place residents at risk of adverse medication reactions and drug diversions.
Findings Included:
Nurse Medication Cart
In an observation and interview on 08/10/22 at 10:00 AM, inventory of the Nurse Medication Cart with LVN
A revealed:
- One (1) open and in-use Lantus insulin pen at room temperature with no open date.
LVN A said when insulin vials or pens are removed from the refrigerator or punctured, nursing staff must
label the container with the date it was opened. She said the open date is used to track the expiration date
and since the insulin pen did not have an open date the expiration dates could not be establish so it could
no longer be used because after the beyond use date insulin loses its efficacy and can become
contaminated. LVN A said nursing staff are expected to check their medication carts for expired and
inappropriately labeled medications such as insulin and once identified they must be discarded in the
locked drug disposal cabinet located in the medication storage room. She said the use of expired insulin
could place residents at risk of ineffective therapy and infection.
South Medication Room
In an observation and interview on 08/10/22 at 10:05 AM, inventory of the South Medication Room with
LVN A revealed:
- Two (2) expired 100 mL IV Bags of Daptomycin 360 mg, an antibiotic, with an expiration date of 07/13/22
in the refrigerator.
LVN A said the medication belonged to a patient that discharged and the discharging nurse was
responsible for removing all of the resident's medications from circulation located in the nursing carts or
medications room. She said administration of expired medications could place residents at risk of adverse
reactions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
In an interview on 08/10/22 at 10:45 AM the Administrator said, once a resident is discharged their
discharge nurse is responsible from removing all of the resident's medications in the medication
carts/rooms. He said the night shift nursing staff are responsible for auditing the medication carts/rooms,
removing any identified expired or inappropriately labeled medications and discarded them in the locked
drug disposal cabinet. The Administrator said expired medications, if administered, could place residents at
[NAME] for medication errors and ADRs.
In an interview on 08/10/22 at 10:55 AM the Interim ADON said, nursing staff are expected to label insulin
pens with the date once they are removed from the fridge or put in use in order to track the expiration date.
She said if an insulin pen had no date it could not be used since its expiration could not be determined. The
Interim ADON said once insulin expires it deteriorates and if used it could place residents at risk for ADRs
due to inadequate therapy. She said that once a resident discharges their discharge nurse is responsible for
removing all of the resident's medications from the med room and med cart. The Interim ADON said that
the night shift nursing staff are responsible from auditing the medication rooms/carts and all expired
medications are to be placed in the locked drug disposal cabinet.
Record review of the facility policy titled Procedure for Medication Storage on Medication Cart revised
02/21/19 revealed, all injectables, eye drops, inhalers, nebulizer solutions, nasal sprays, ear drops, and
blood glucose test strips will be dated once opened and discarded per manufacturer's storage guidelines
specified on box. Must promptly pull medications from cart once medication is discontinued, resident is
discharged to hospital, medication is expired. All discontinued and expired medications must be stored in
the locked cabinet in the medication room designated for storage of discontinued and expired medications
until turned into the nursing director for destruction.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve
food in accordance with professional standards for food service safety in the facility's only kitchen.
Residents Affected - Many
-The facility failed to ensure the proper labeling and dating of all foods stored in the walk-in cooler, and
freezer.
-The facility failed to ensure proper discarding of expired food stored in the walk-in cooler and freezer.
-The sanitizing solution water in the three-compartment sink was above the manufacture recommendation.
These failures could place residents at risk for food-borne illnesses.
Findings included:
Observation on 08/09/22 at 9:30 a.m., of the kitchen walk in cooler revealed the following:
A container of prepped tuna was not dated,
A bag of citronella leaf was open and not dated.
Two 22 Liters of vegetable soup were not dated with Prep and discard date.
Two 22 litters of tomatoes soup were not dated with Prep and discard date
Opened micro greens and it was expired on 07/28/22.
two head of lettuce was in a Ziploc bag, and it was open. the lettuce also brown in color, wilted and the
expiration date was 07/30/22
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
two heads of prepped cabbage in a Ziploc bag and another one in a bag by itself and the bags was open.
there were brown streaks all over the three heads of cabbage and the expiration date was 07/25/22
Level of Harm - Minimal harm
or potential for actual harm
Observation on 08/09/22 at 9:43 a.m., revealed the following in the freezer
Residents Affected - Many
long pan of carrot pastes expired 08/05/22
a small pan of Roseto was not dated
a medium pan of sausage was not dated
27 frozen cookies were left open in the freezer.
A loaf of bread had a prep date of 06/20/22 and discard date of 12/20/22
A loaf of bread had a prep date of 06/02/22 and a dis card date of 06/02/23.
Observation 08/09/22 at 9:50 a.m. of the three-compartment sink revealed the sanitized water had excess
sanitizing solution as indicated by the test strip which was dark green indicating the sanitizing solution was
500 ppm or more. The test strip range should be between 200 ppm and 400 ppm which were lighter colors.
Interview on 08/09/22 at 10:20 a.m. The chef said the chemical for sanitizing the plates and cookware in the
three-compartment sink should be between 200 and 400 psi, but it was green which was 500 psi and
above. He said if the plates or cookware had a lot of residues, it could irritate the resident's stomach
because there was more than the recommended quantity of the sanitizing solution in the water.
Interview on 08/09/22 at 10:05 a.m., the chef said prepped food or soup should be dated with the prep date
and discard date. He also stated any opened produce is stored in a Ziploc bag, and all air is removed from
the bag before it is closed to keep the produce fresh. The chef said if food is left open in the freezer, it could
have freezer burn, and it is not safe to serve the residents. He said food should be stored in a safe and
sanitary condition to prevent residents from getting sick; the food must be labeled prep or open, discard
date, and pulled out of the cooler and freezer as soon as it expired. The chef said he was responsible for
checking the cooler and freezer to ensure the food was stored properly and there was no expired food, but
he failed to make sure all expired food was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
pulled. He said he in-serviced the cooks on how to save food with dates and confirmed the bags were
closed. He said he put the two loaves of bread in the freezer with those dates, but the facility did not have a
policy for bread to be frozen. He did not respond on why the two loaves of bread were frozen.
Interview on 08/11/22 at 10:47 a.m., The administrator said when the food is delivered, it is broken down
and stored in the appropriate place and dated appropriately. He said soup that was prepared should be
dated by whoever made it. He said expired items are discarded at the time of expiration. He said the facility
policy is not to freeze bread to extend the self-live. He said if a resident is served expired food, there is a
potential for the resident to get sick. He said he does not think a resident would have any negative outcome
if the resident was served with a plate or utensil sanitized in water with more solution.
Interview on 08/12/22 at 11:29 a.m. [NAME] A said he prepped the soups, and he forgot to label the soups
with the prep date and discard date because he got busy. He said if food is placed in a Ziploc bag, he will
make sure that all the air was left out of the bag before he closed the bag and then labeled it accordingly.
He also said if any food was not in its original packet and it was also opened, it should be labeled too.
Record review of the facility policy on food storage dated 2013 read in part . #14f . all foods should be
covered, labeled and dated, fall foods will be checked to assure that foods will be consumed by their safe
use by dates or discard .
Record review of a ECOLAB manufacturer instruction guide dated 2013 eco lab USA Ink read in part . multi
- quat sanitizer no -rise .testing solution should be between 200 - 400 ppm .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
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