Health inspection·August 12, 2022

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 Page 1 of 10 676423 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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 . 676423 Page 2 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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 676423 Page 3 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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. 676423 Page 4 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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 676423 Page 5 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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. 676423 Page 6 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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. 676423 Page 7 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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 676423 Page 8 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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 676423 Page 9 of 10 676423 08/12/2022 The Hallmark 4718 Hallmark Dr Houston, TX 77056

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 . 676423 Page 10 of 10