6 CMS Surveys
Inspection Report — May 13, 2025
Routine
Date: May 13, 2025
Visit Reason
Routine state inspection of Hallmark Manor nursing facility to assess compliance with regulatory requirements including resident care, medication management, environment safety, infection control, and documentation.
Findings
The facility was found to have multiple deficiencies including failure to provide required notifications, maintain a homelike environment, document transfers and notifications, complete assessments and care plans timely, ensure safe medication administration and storage, provide adequate assistance with activities of daily living, and follow infection control practices. Several residents were at risk due to these failures. Some meals served were unappetizing and not properly substituted. The facility did not consistently follow up on pharmacist medication reviews or monitor bed rail use. Infection control lapses and unsecured hazardous materials were observed.
Deficiencies (16)
WAC 388-97-0300(1)(e),(5),(6) - Facility failed to provide required Notification of Medicare Non-Coverage (NOMNC) to Resident 247 before Medicare coverage ended, risking resident's understanding of benefits.
WAC 388-97-0880 - Facility failed to maintain a safe, clean, and homelike environment; resident rooms lacked personal décor and weight scales in shower rooms were rusty, posing risk to residents.
WAC 388-97-0120(2)(a-d)(3)(a)(4), -0140(1)(a)(b)(c)(i-iii) - Facility failed to provide written transfer notices, bed hold policies, call reports to receiving hospitals, and notify Ombudsman and medical providers for multiple residents transferred or discharged.
WAC 388-97-1000(3)(b) - Facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for Resident 92 after decline and hospice enrollment, risking unmet care needs.
WAC 388-97-1000 (1)(b) - Facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Resident 94's discharge status and Resident 1's fall history, risking unmet needs.
WAC 388-97-1915(4) - Facility failed to obtain PASRR Level 2 evaluations for 5 residents with Serious Mental Illness, risking inadequate mental health care.
WAC 388-97-1020(1), (2)(a)(b) - Facility failed to develop a Palliative care plan for Resident 92, risking unmet care needs and decreased quality of life.
WAC 388-97-1020(4)(e),(5)(b) - Facility failed to conduct quarterly care conferences for Residents 1, 50, and 64 and failed to revise care plans for Residents 71 and 88, risking unmet care needs and confusion.
WAC 388-97-1060(2)(c) - Facility failed to provide adequate assistance with activities of daily living for Residents 46, 61, and 62, risking poor hygiene and negative health outcomes.
WAC 388-97-1060 (1) - Facility failed to monitor laboratory values for Residents 80 and 88, failed to report changes of condition for Residents 44 and 46, and failed to administer pain medications as ordered for Resident 65, risking adverse outcomes.
WAC 388-97-1060(3)(g) - Facility failed to secure chemicals and sharps in multiple units and storage rooms, risking resident exposure to hazards.
WAC 388-97-1300(1)(c)(iii), (4)(c) - Facility failed to ensure licensed pharmacist medication regimen reviews were documented, reviewed, and acted upon timely for Residents 1 and 35, risking medication errors and adverse effects.
WAC 388-97-1060(3)(k)(i) - Facility failed to evaluate the need for continued use of an antibiotic for Resident 26, risking unnecessary medication use and adverse effects.
WAC 388-97-1300(2), -2340 - Facility failed to properly label and store medications in medication carts and hall storage areas, risking expired medication use and accidental ingestion.
WAC 388-97-1100(1)(2) - Facility served green, unappetizing eggs and failed to offer alternate meals to residents, risking inadequate nutritional intake and dissatisfaction.
WAC 388-97-1320 (1)(a),(c) - Facility failed to ensure staff performed hand hygiene and followed enhanced barrier precautions for Resident 50, risking transmission of communicable diseases.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 8
Inspection Report — Aug 19, 2024
Complaint Investigation
Date: Aug 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's food and nutrition services, focusing on staff qualifications and food safety practices.
Complaint Details
The complaint investigation revealed multiple food safety violations including unqualified dietary management staff and unsafe food handling practices. The allegations were substantiated with findings of improper certifications and unsafe food temperatures, cross-contamination, poor hygiene, pest presence, and expired/unlabeled foods.
Findings
The facility failed to ensure the Dietary Manager had required certifications and failed to maintain proper food safety standards including temperature control, cross-contamination prevention, food labeling, pest control, kitchen cleanliness, and timely meal service. These deficiencies placed all residents at risk of foodborne illness and diminished quality of life.
Deficiencies (2)
WAC 388-97-1160 (2)(3)(a)(b)(i) - The facility failed to ensure the Dietary Manager had the required ServSafe Manager Certification and was not registered for the Certified Dietary Manager course as required for employment.
WAC 388-98-1100(3), -2980 - The facility failed to procure food from approved sources and store, prepare, distribute, and serve food according to professional standards, including failure to check food temperatures, prevent cross-contamination, label and date refrigerated foods, discard expired foods, prevent pests, clean kitchen vents, perform proper hand hygiene, and serve meals timely.
Report Facts
Residents affected: 92
Food temperatures observed: 90.3
Food temperatures observed: 130.7
Food temperatures observed: 120.4
Food temperatures observed: 100
Food temperatures observed: 115.1
Food temperatures observed: 118.9
Food temperatures observed: 114.8
Food temperatures observed: 60.2
Food temperatures observed: 67.3
Inspection Report — Jun 12, 2024
Complaint Investigation
Date: 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.
Complaint Details
The complaint investigation involved Resident 1 who developed a facility-acquired deep tissue injury and open wound on the right foot. The investigation revealed that the resident's care plan was not updated after cast removal, the brace was not removed for skin checks, and staff did not perform range of motion exercises on the affected leg. The resident was hospitalized and scheduled for an above-the-knee amputation. The complaint was substantiated.
Findings
The facility failed to provide necessary treatment and services to prevent an avoidable pressure ulcer in one sampled resident, resulting in actual harm including hospital admission and scheduled amputation. The investigation found inadequate skin checks, unclear care plan revisions, and failure to remove the brace for proper wound assessment.
Deficiencies (1)
WAC 388-97-1060(3)(b) - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to a resident who developed an unstageable pressure injury requiring hospitalization and scheduled amputation.
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
Inspection Report — May 10, 2024
Complaint Investigation
Date: May 10, 2024
Visit Reason
The inspection was conducted due to allegations of abuse and failure to obtain and document COVID-19 laboratory testing properly at the facility.
Complaint Details
The complaint involved allegations of abuse to Residents 1 and 8. Resident 1 was verbally abused by Staff E, who was allowed to continue working until suspended and terminated days later. Resident 8 reported being grabbed and placed on the ground, but no formal allegation was reported by staff. The investigation found failures in timely reporting and investigation of abuse allegations.
Findings
The facility failed to respond timely to abuse allegations involving two residents and allowed an alleged perpetrator to continue working before suspension. Additionally, the facility failed to obtain physician orders for COVID-19 testing and did not document test results for several residents, increasing the risk of delayed diagnosis.
Deficiencies (2)
WAC 388-97-0640(2)(b)(5)(6)(b) - The facility failed to respond appropriately and timely to abuse allegations for 2 of 3 sampled residents, including not suspending the alleged perpetrator pending investigation and delayed notification and monitoring of the alleged victims.
WAC 388-97-1340 (1)(2)(3) - The facility failed to obtain physician orders for COVID-19 testing and did not document test results for multiple residents during a COVID-19 outbreak, increasing the likelihood of delayed identification and diagnosis.
Report Facts
Residents reviewed for COVID-19 testing: 10
Residents without physician orders for COVID-19 testing: 6
Residents without documented COVID-19 test results: 3
Residents affected by abuse deficiency: 2
Inspection Report — Mar 6, 2024
Routine
Date: Mar 6, 2024
Visit Reason
The inspection was a routine state survey to assess compliance with regulatory requirements including resident care, medication administration, infection control, dietary services, and safety.
Findings
The facility was found deficient in multiple areas including resident dignity and communication, timely notification of transfers and bed-hold policies, completion and accuracy of assessments, care plan revisions, medication administration errors, medication storage, infection prevention practices, dietary accommodations, respiratory care, dialysis communication, restorative nursing services, and resident supervision. Several residents experienced risks due to these deficiencies, but no immediate harm was indicated.
Deficiencies (16)
WAC 388-97-0180(1-4) - The facility failed to provide care that promoted resident dignity for 5 residents, including improper communication pace, failure to address preferred names, and uncovered catheter bags.
WAC 388-97-0120 (2)(a-d) - The facility failed to provide timely written notification of transfers/discharges and bed-hold policies to residents or their representatives for 4 residents.
WAC 388-97-1000(3)(b) - The facility failed to complete a Significant Change Minimum Data Set timely for 1 resident.
WAC 388-97--1000 (1)(b) - The facility failed to ensure accurate Minimum Data Set assessments for 4 residents, including inaccurate medication and behavioral coding.
WAC 388-97-1915 (1)(2)(a-c) - The facility failed to timely request a Level 2 PASRR evaluation for 1 resident with serious mental illness indicators.
WAC 388-97-1020(2)(c)(d) - The facility failed to revise care plans as needed for 6 residents, resulting in outdated interventions and unmet care needs.
WAC 388-97-1060(3)(d) - The facility failed to provide restorative nursing services as ordered for 3 residents, with missed sessions and inadequate documentation.
WAC 388-97-1060 (3)(g) - The facility failed to provide adequate supervision and accident prevention for 2 residents, resulting in repeated falls and wandering incidents.
WAC 388-97-1060(3)(vi) - The facility failed to ensure oxygen tubing was changed weekly, oxygen tanks were not empty, and oxygen concentrators were set per orders for 2 residents.
WAC 388-97-1900 (1)(6)(a-c) - The facility failed to maintain ongoing communication and collaboration with the dialysis center for 1 resident receiving hemodialysis.
WAC 388-91-1060 (3)(k)(ii) - The facility failed to properly administer medications, resulting in a medication error rate of 22.22% for 3 residents observed during medication pass.
WAC 388-97-1300(2) - The facility failed to appropriately store controlled medications in a double-locked system and failed to secure a treatment cart containing medications.
WAC 388-97-1320 (2)(b), -1320 (1)(c) - The facility failed to ensure staff performed proper hand hygiene and used appropriate PPE, including wearing masks correctly and using respirators when required.
WAC 388-97-1040 (1)(a-c) - The facility failed to develop and implement a comprehensive person-centered care plan for a resident with dementia, resulting in inadequate management of dementia symptoms and behaviors.
WAC 388-97-1120 - The facility failed to provide meals that accommodated resident allergies, intolerances, and preferences for 5 residents, resulting in frustration and risk of weight loss.
WAC 388-97 -1160 (1) - The facility failed to store food in a clean, safe, and sanitary manner, including undated and improperly stored food items and dented cans in the kitchen.
Report Facts
Medication error rate: 22.22
Residents affected by dignity failure: 5
Residents affected by transfer notification failure: 4
Residents affected by care plan revision failure: 6
Residents affected by restorative nursing failure: 3
Residents affected by supervision failure: 2
Residents affected by respiratory care failure: 2
Residents affected by dialysis communication failure: 1
Residents affected by medication storage failure: 1
Residents affected by infection control failure: 2
Residents affected by dietary failure: 5
Inspection Report — Nov 8, 2022
Routine
Date: Nov 8, 2022
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, staffing, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to assist residents with advance directives, inaccurate mental health screening, inadequate assistance with activities of daily living such as bathing, failure to implement restorative nursing programs, unsafe pain management, lack of dialysis care coordination, insufficient nursing staffing, incomplete nurse aide registry verification, medication management errors, expired and unsecured medications, deficient infection control practices including improper cleaning and incomplete staff vaccination verification, failure to maintain an effective antibiotic stewardship program, and incomplete quality assurance meetings. Several residents were at risk due to these deficiencies.
Deficiencies (18)
F 0578 - The facility failed to assist or provide referrals for 8 of 18 residents to formulate advance directives, leaving residents at risk of losing their right to have care preferences honored.
F 0645 - The facility failed to ensure accurate PASARR mental health screening for 5 of 7 residents reviewed, risking inappropriate placement and unmet mental health needs.
F 0677 - The facility failed to provide consistent assistance with activities of daily living, including bathing, for 7 of 7 residents reviewed, resulting in poor hygiene and diminished quality of life.
F 0688 - The facility failed to implement restorative nursing programs for 5 residents after discharge from therapy, risking functional decline and loss of mobility.
F 0697 - The facility failed to recognize and treat pain appropriately for Resident 24, resulting in daily episodes of untreated pain and decreased quality of life.
F 0698 - The facility failed to establish effective dialysis care coordination for Resident 74, including missing dialysis agreements and incomplete weight monitoring, risking fluid overload and adverse outcomes.
F 0725 - The facility failed to maintain sufficient nursing staff to meet resident needs, resulting in unmet care needs, delayed call light response, and inadequate infection control and restorative nursing programs.
F 0729 - The facility failed to verify nurse aide competency through state registry verification for 3 CNAs prior to hire, risking resident safety and care quality.
F 0755 - The facility failed to maintain accurate and complete controlled substance inventory records on two medication carts, risking drug diversion and resident safety.
F 0758 - The facility failed to obtain informed consent, monitor target behaviors, implement non-drug interventions, and conduct gradual dose reductions for psychotropic medications for multiple residents, risking overmedication and diminished quality of life.
F 0759 - The facility failed to maintain a medication error rate below 5%, with a 28% error rate observed due to failure to verify resident identity prior to medication administration.
F 0761 - The facility failed to ensure hand hygiene during medication administration and proper cleaning of reusable medical equipment, risking transmission of infections.
F 0781 - The facility failed to ensure expired medications and vaccines were removed timely and failed to secure medications during administration, risking compromised medication potency and resident safety.
F 0867 - The facility failed to maintain an effective Quality Assessment and Assurance program with regular meetings and required participants, limiting oversight of quality deficiencies.
F 0880 - The facility failed to implement infection prevention practices including cleaning of vital sign equipment between residents and ensuring N95 respirator fit testing for staff, risking transmission of communicable diseases including Covid-19.
F 0881 - The facility failed to implement an antibiotic stewardship program ensuring appropriate antibiotic use, with multiple residents treated without meeting infection criteria, risking adverse outcomes and antibiotic resistance.
F 0883 - The facility failed to ensure influenza and pneumococcal vaccinations were offered and administered to residents as required, placing residents at risk for preventable infections.
F 0888 - The facility failed to verify Covid-19 vaccination status for contracted staff providing direct resident care, risking transmission of Covid-19 infection.
Report Facts
Medication error rate: 28
Residents reviewed for advance directives: 18
Residents reviewed for PASARR accuracy: 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
Residents reviewed for antibiotic stewardship: 6
Staff shifts worked by unvaccinated practitioner: 8
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