Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
190% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
92 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 15
May 13, 2025
Visit Reason
Routine inspection of Hallmark Manor nursing home to assess compliance with regulatory requirements including resident care, safety, medication management, infection control, and facility environment.
Findings
The facility had multiple deficiencies including failure to provide required Medicare liability notices, maintain a homelike environment, provide required transfer and discharge notifications, complete significant change assessments, ensure accurate Minimum Data Set assessments, obtain necessary PASRR Level 2 evaluations, develop palliative care plans, conduct quarterly care conferences, ensure professional standards in medication management, provide adequate assistance with activities of daily living, ensure proper medication storage and labeling, provide palatable meals, and follow infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to provide required Notification of Medicare Non-Coverage (NOMNC) to Resident 247 before Medicare coverage ended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a safe, clean, and homelike environment; resident rooms lacked personalization and weight scales were rusty. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide required documentation or notification related to resident transfers including bed hold policies, transfer notices, call reports, and LTCO notifications for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete Significant Change in Status Assessment (SCSA) for Resident 92 enrolled in hospice care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Minimum Data Set (MDS) assessments accurately reflected resident status for Residents 1 and 94. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain PASRR Level 2 evaluations for 5 residents with Serious Mental Illness (SMI) after Level 1 PASRR indicated need. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a Palliative care plan for Resident 92 receiving comfort care services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to facilitate quarterly care conferences for Residents 1, 50, and 64 and failed to revise care plans as required for Residents 71 and 88. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders were obtained for bed rails and blood sugar parameters, clarify physician orders, and administer medications within ordered parameters for Residents 80, 88, and 1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate assistance with activities of daily living for Residents 46, 61, and 62, including supervision during meals and nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders, resident preferences and goals, including monitoring for changes in condition and pain management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure licensed pharmacist monthly medication regimen reviews were added to resident records and recommendations reviewed and acted upon for Residents 35 and 1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper storage and labeling of medications in medication carts and storage rooms, including undated inhalers and unsecured medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and serve foods that were palatable, attractive, and at a safe and appetizing temperature; residents reported green eggs and lack of alternate meal options. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff followed infection control practices including hand hygiene and use of enhanced barrier precautions for Resident 50. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication Administration: 5
Weight entries: 211
Weight entries: 96
Medication Regimen Review reports: 3
Medication Regimen Review reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Reviewed multiple findings including medication management, care planning, infection control, and confirmed deficiencies. |
| Staff C | Social Services Director | Interviewed regarding PASRR referrals, care conferences, and transfer notifications. |
| Staff F | Regional Director of Clinical Services | Reviewed medication management and care plan deficiencies. |
| Staff I | Resident Care Manager | Interviewed regarding weight monitoring, medication administration, and care plan interventions. |
| Staff J | Infection Preventionist | Interviewed regarding antibiotic medication follow-up. |
| Staff H | Registered Nurse | Observed and interviewed regarding resident foot care and edema. |
| Staff G | Social Service Assistant | Interviewed regarding PASRR referrals, care conferences, and podiatrist referrals. |
| Staff S | Registered Nurse | Interviewed regarding medication storage and infection control practices. |
| Staff V | Licensed Practical Nurse | Interviewed regarding medication storage and inhaler open dates. |
| Staff B | Director of Nursing | Reviewed Resident 50 infection control failures. |
Inspection Report
Routine
Census: 92
Deficiencies: 8
Aug 19, 2024
Visit Reason
The inspection was conducted to assess compliance with food and nutrition service regulations, including staff qualifications and food safety practices.
Findings
The facility failed to ensure the Dietary Manager had required certifications and failed to maintain proper food safety standards, including temperature control, prevention of cross-contamination, labeling and dating of foods, pest control, kitchen cleanliness, and timely meal service, placing residents at risk of foodborne illness and diminished quality of life.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Dietary Manager (Staff C) lacked required ServSafe Manager Certification and was not registered for Certified Dietary Manager course. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to check food temperatures before serving; hot foods served within the Danger Zone temperature range. | Level of Harm - Minimal harm or potential for actual harm |
| Cross-contamination observed with cracked eggshells placed on whole eggs and improper handling. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate hand hygiene observed among kitchen staff. | Level of Harm - Minimal harm or potential for actual harm |
| Meals served later than posted mealtimes. | Level of Harm - Minimal harm or potential for actual harm |
| Food storage issues including unlabeled, undated, and expired foods in walk-in refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Presence of fruit flies in dry storage room near food items. | Level of Harm - Minimal harm or potential for actual harm |
| Kitchen vents covered in removable dark grey debris. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 92
Food temperatures: 90.3
Food temperatures: 130.7
Food temperatures: 120.4
Food temperatures: 100
Food temperatures: 115.1
Food temperatures: 118.9
Food temperatures: 114.8
Food temperatures: 60.2
Food temperatures: 67.3
Meal cart departure times: 7.54
Meal cart departure times: 8.15
Meal cart departure times: 8.4
Meal cart departure times: 9.01
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Manager | Named in deficiency for lacking required certifications and improper food handling |
| Staff A | Administrator | Provided statements regarding staff qualifications, food safety expectations, and observations |
| Staff B | Cook | Observed failing to check food temperatures and improper handwashing |
| Staff D | Dietary Aide | Observed improper hand hygiene and food handling |
| Staff E | Dietary Aide | Observed setting up trays and commenting on food quality |
| Staff H | Certified Nursing Assistant | Present during food temperature checks |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in a resident.
Findings
The facility failed to provide necessary treatment and services to prevent an avoidable pressure ulcer in one resident, resulting in an unstageable wound requiring hospital treatment and eventual above-the-knee amputation. The investigation revealed inadequate skin checks, unclear care plan revisions after cast removal, and failure to remove the brace for skin inspection.
Complaint Details
The complaint investigation found that Resident 1 developed a facility-acquired deep tissue injury and open wound on the right foot and 5th toe, which worsened to a necrotic ulcer with exposed bone, leading to hospital admission and scheduled amputation. The wounds were attributed to pressure from the resident's preference of lying on the right side and inadequate care related to the immobilizer and brace management. The facility's failure to clarify care plan instructions and perform appropriate skin checks was noted.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. | Level of Harm - Actual harm |
Report Facts
Residents affected: 1
Wound measurements: 3
Wound measurements: 5
Wound measurements: 0.6
Wound measurements: 5
Wound measurements: 13
Wound measurements: 0.5
Dates: Feb 21, 2024
Dates: May 6, 2024
Dates: Dec 29, 2023
Dates: Apr 22, 2024
Dates: May 14, 2024
Dates: May 20, 2024
Dates: May 21, 2024
Dates: May 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Acknowledged care plan was not revised after cast removal to include removal of brace for skin checks |
| Staff C | Restorative Nursing Assistant | Performed ROM on Resident 1's unaffected limbs but not on affected right lower extremity |
| Staff D | Licensed Practical Nurse | Checked circulation in resident's toes and stated splint was not removed during care |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 10, 2024
Visit Reason
The inspection was conducted due to allegations of abuse and failure to follow proper procedures in responding to abuse allegations, as well as concerns regarding laboratory testing and documentation for COVID-19 among residents.
Findings
The facility failed to respond timely to abuse allegations for 2 of 3 sampled residents, allowed an alleged perpetrator to continue working before suspension, and failed to ensure proper COVID-19 testing orders and documentation for 8 of 10 residents reviewed. These failures placed residents at risk for harm and delayed identification of COVID-19 cases.
Complaint Details
The complaint investigation revealed failure to timely respond to abuse allegations involving Resident 1 and Resident 8, failure to suspend the alleged perpetrator pending investigation, and failure to follow proper COVID-19 testing protocols including missing physician orders and undocumented test results. Staff interviews and record reviews confirmed these issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to respond to abuse allegations in a timely manner and failed to protect residents from further potential abuse by allowing alleged perpetrator to continue working. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain laboratory services according to professional standards for COVID-19 testing, including lack of physician orders and failure to document test results. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for COVID-19 testing: 10
Residents without physician orders for COVID-19 testing: 6
Residents with undocumented COVID-19 test results: 3
Residents affected by abuse allegation deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant (CNA) | Alleged perpetrator allowed to continue working after abuse allegation |
| Staff D | Certified Nursing Assistant (CNA) | Witnessed and reported verbal abuse incident involving Staff E |
| Staff F | Registered Nurse (RN) | Received report of abuse incident but failed to follow up |
| Staff B | Director of Nursing | Interviewed regarding abuse allegations and COVID-19 testing procedures |
| Staff C | Licensed Practical Nurse, Infection Preventionist | Interviewed regarding COVID-19 testing orders and procedures |
Inspection Report
Routine
Census: 24
Deficiencies: 14
Mar 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, transfer and discharge notifications, care planning, medication administration, infection control, and other aspects of nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide care that promoted resident dignity, failure to provide timely and written transfer/discharge notifications, failure to complete timely assessments and accurate care plans, medication administration errors, inadequate infection prevention practices, improper medication and food storage, and failure to provide restorative nursing and respiratory care according to professional standards.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to provide care and services in a manner that promoted resident dignity for 5 of 24 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification to residents and representatives before transfer or discharge for 4 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written notice of bed-hold policy at time of transfer or within 24 hours for 4 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete a Significant Change Minimum Data Set (SCSA) timely for 1 of 24 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Minimum Data Set (MDS) assessments were completed accurately for 4 of 24 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to request timely Level 2 PASRR evaluation for 1 of 6 residents reviewed for PASRR. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise care plans as needed for 6 of 24 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure services met professional standards of quality including following physician orders, clarifying orders, signing only for completed tasks, and providing rationale for late onset mental health condition for 5 of 24 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide restorative nursing services as ordered for 1 resident reviewed for rehab/restorative and 2 supplementary residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and thorough accident investigation for 2 of 11 residents reviewed for accidents and supervision. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide respiratory care within professional standards for 2 of 4 residents reviewed for respiratory care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to appropriately store drugs and biologicals in locked compartments for 1 of 2 medication storage rooms and 1 of 2 treatment carts reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide food that accommodated resident allergies, intolerances, and preferences for 5 of 7 residents reviewed for preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish and maintain an infection prevention and control program including proper hand hygiene and PPE use on 2 of 2 units. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 24
Medication error rate: 22.22
Residents affected by dignity deficiency: 5
Residents affected by transfer notification deficiency: 4
Residents affected by bed-hold notification deficiency: 4
Residents affected by restorative nursing deficiency: 3
Residents affected by supervision deficiency: 2
Residents affected by respiratory care deficiency: 2
Residents affected by medication storage deficiency: 2
Residents affected by food preference deficiency: 5
Residents affected by infection control deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Registered Nurse | Named in medication administration and infection control findings |
| Staff AA | Licensed Practical Nurse | Named in medication administration findings |
| Staff BB | Registered Nurse | Named in medication administration findings |
| Staff C | Unit Care Manager | Named in multiple findings including dignity, transfer notification, restorative nursing, respiratory care, and medication administration |
| Staff D | Unit Care Manager | Named in multiple findings including dignity, restorative nursing, respiratory care, dialysis communication, and medication administration |
| Staff B | Interim Director of Nursing | Named in multiple findings including transfer notification, restorative nursing, respiratory care, medication administration, medication storage, and dialysis communication |
| Staff G | Food Service Director | Named in food preference findings |
| Staff H | Infection Preventionist | Named in infection control findings |
| Staff K | Certified Nursing Assistant | Named in infection control findings |
| Staff X | Certified Nursing Assistant | Named in infection control findings |
| Staff Y | Certified Nursing Assistant | Named in infection control findings |
| Staff J | Certified Nursing Assistant | Named in supervision findings |
| Staff O | Certified Nursing Assistant | Named in restorative nursing and medication administration findings |
| Staff Q | MDS Nurse | Named in MDS accuracy findings |
| Staff F | Social Service Director | Named in transfer notification and PASRR findings |
| Staff M | Social Services Assistant | Named in PASRR findings |
| Staff E | Business Office Manager | Named in transfer notification and bed-hold notification findings |
| Staff V | Certified Nursing Assistant | Named in dignity findings |
| Staff DD | Certified Nursing Assistant | Named in dignity findings |
| Staff AA | Licensed Practical Nurse | Named in medication administration findings |
| Staff BB | Registered Nurse | Named in medication administration findings |
| Staff N | Registered Nurse | Named in medication storage findings |
| Staff CC | Certified Nursing Assistant | Named in infection control findings |
Inspection Report
Routine
Deficiencies: 15
Nov 8, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, infection control, medication management, staffing, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights regarding advance directives, inaccurate PASARR assessments, inadequate assistance with activities of daily living including bathing, failure to implement restorative nursing programs, inadequate pain management, failure to ensure safe dialysis care, insufficient nursing staff, incomplete nurse aide registry verification, medication management errors, infection prevention and control deficiencies, lack of antibiotic stewardship, incomplete quality assurance activities, and failure to ensure staff vaccination compliance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to honor residents' rights to request, refuse, and/or discontinue treatment, and to formulate advance directives for 8 of 18 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Inaccurate PASARR assessments and failure to complete PASARR for 5 of 7 residents reviewed, risking inappropriate placement and unmet mental health needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with activities of daily living, including bathing, for 7 of 7 residents reviewed, resulting in poor hygiene and diminished quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement restorative nursing programs for 5 residents, risking functional decline and loss of range of motion. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate pain management for 1 of 3 residents reviewed, resulting in untreated pain and decreased quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safe dialysis care and ongoing collaboration with dialysis center for 1 resident, risking fluid overload and negative health outcomes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have sufficient nursing staff to meet resident needs, maintain infection control, provide restorative nursing, and timely respond to call lights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to verify nurse aide competency prior to start date for 3 staff, risking unmet care needs and abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate reconciliation and accounting of controlled medications in multiple medication carts, risking drug diversion. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure expired medications and vaccines were disposed of timely and failure to secure medications during administration for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective Quality Assessment and Assurance program with regular meetings and required participants. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention and control practices including hand hygiene, equipment cleaning, and N95 respirator fit testing for staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an antibiotic stewardship program to promote appropriate antibiotic use and reduce resistance for 5 of 6 residents treated with antibiotics. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for influenza and pneumococcal vaccinations, resulting in residents not receiving recommended immunizations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure staff completed required COVID-19 vaccination verification for contracted staff, placing residents and others at risk. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 28
Residents reviewed for advance directives: 18
Residents reviewed for PASARR: 7
Residents reviewed for ADL assistance: 7
Residents reviewed for restorative nursing program: 5
Residents reviewed for pain management: 3
Residents reviewed for dialysis care: 1
Staff reviewed for nurse aide registry verification: 5
Medication carts reviewed: 4
Expired medications found: 53
Residents reviewed for immunizations: 5
Staff shifts worked without COVID-19 vaccination verification: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Business Office Manager | Mentioned in relation to advance directive documentation and retrieval. |
| Staff C | Director of Social Services | Mentioned in relation to advance directive assistance and PASARR accuracy. |
| Staff E | Licensed Practical Nurse/Unit Care Coordinator | Mentioned in relation to multiple findings including advance directives, restorative nursing, pain management, dialysis care, medication accountability, and infection control. |
| Staff B | Director of Nursing | Mentioned in relation to restorative nursing program, medication error investigation, infection control, and quality assurance. |
| Staff A | Administrator | Mentioned in relation to staffing, quality assurance, and infection control oversight. |
| Staff N | Restorative Aide | Mentioned regarding restorative nursing program staffing and fit testing. |
| Staff F | Licensed Practical Nurse/Unit Care Coordinator | Mentioned regarding medication administration, restorative nursing, infection control, and antibiotic stewardship. |
| Staff U | Licensed Practical Nurse | Mentioned regarding medication cart controlled substance inventory and expired medications. |
| Staff W | Agency Licensed Practical Nurse | Mentioned regarding medication error and controlled substance inventory. |
| Staff M | Staff | Mentioned regarding lack of COVID-19 vaccination and missing N95 fit testing. |
| Staff Z | Practitioner | Mentioned regarding lack of COVID-19 vaccination verification. |
| Staff AA | Practitioner | Mentioned regarding lack of COVID-19 vaccination verification. |
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