Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hallmark Manor during CMS and state inspections, most recent first.
A resident with stroke-related deficits, memory impairment, partial paralysis, and dependence for transfers reported increased leg pain and later was found to have a right ankle fracture. The RN only checked the knee, did not assess the full leg or notify the provider, and the resident was not sent out until later when an LPN found severe pain with ankle swelling, redness, and warmth; the resident and family reported hearing a popping noise during care and waiting hours in pain before hospital transfer.
Staff did not provide required written transfer notifications, bed hold policies, or call reports to the receiving hospital for several residents transferred to acute care. In some cases, residents or their representatives were not informed of the transfer or their rights, and documentation of these actions was missing. The facility also failed to notify the LTCO and medical providers as required.
Hazardous chemicals and sharps were found unsecured in multiple areas, including shower rooms and storage rooms, with doors left open or unlocked and no staff present. Items such as cleaning agents, razors, and scissors were accessible to residents, and staff confirmed these should have been secured according to facility policy.
A resident was discharged to an adult family home without being provided the required Notification of Medicare Non-Coverage (NOMNC) prior to discharge. Documentation confirmed the discharge was planned, but the NOMNC letter was not issued, as verified by the Social Service Director.
Multiple resident rooms lacked personal items or décor, with some rooms noted to have strong odors and inadequate lighting that persisted despite being reported. Weight scales in both shower rooms were found to be rusted, with staff confirming the potential for resident contact with rust. These deficiencies were observed and confirmed through staff and resident interviews, indicating a failure to maintain a safe, clean, and homelike environment.
A resident experienced multiple declines in condition, including increased confusion, immobility, refusal of food and fluids, and was placed on hospice care. Despite these changes, staff did not complete a Significant Change in Status Assessment (SCSA) as required, as confirmed by record review and staff interviews.
Surveyors found that the facility failed to accurately complete MDS assessments for two residents: one resident's fall was not documented in the MDS despite being recorded in progress notes, and another resident's discharge was incorrectly coded as a hospital transfer instead of a discharge to home, as confirmed by staff and records.
The facility did not ensure that PASRR Level 2 evaluations were obtained for several residents with serious mental illness, as required after positive Level 1 screenings or new mental health diagnoses. Documentation and staff interviews revealed that referrals were either not made or not followed up on, resulting in missing or incomplete evaluations for residents with conditions such as depression, anxiety, and psychotic disorders.
A resident who had agreed to Palliative care services did not have a Palliative care plan developed, as confirmed by record review and DON interview. This omission was not in accordance with facility policy requiring timely, person-centered care plans.
The facility did not consistently conduct or document quarterly care conferences for three residents, including one with diabetes and mental health conditions, another in a persistent vegetative state, and a third without memory impairment. Additionally, care plans were not revised as required for two residents: one with respiratory failure whose care plan was not updated after discontinuing oxygen, and another with complex medical needs whose care plan lacked interventions for repeated refusals to be weighed. Staff interviews confirmed inconsistent processes for care conferences and care plan updates.
The facility did not obtain or clarify necessary physician orders for bed rails and blood sugar parameters for a resident with diabetes, failed to follow medication administration parameters for a resident with hypertension, and did not ensure blood pressure checks were performed before administering a diuretic to another resident, as required by physician orders. Staff interviews confirmed these deficiencies.
Staff failed to provide necessary ADL assistance and supervision for three dependent residents, including leaving a resident in a wheelchair for extended periods, not providing nail and foot care for a diabetic resident, and not supervising a hospice resident during meals as required by care plans and facility policy.
The facility failed to obtain required lab tests before administering medications for cholesterol, uric acid, and thyroid conditions, did not consistently observe or report changes in condition such as edema or infection in two residents, and did not administer pain medications as ordered for a resident with chronic pain. These actions resulted in residents receiving medications without proper monitoring and experiencing unaddressed changes in their health status.
Staff did not consistently assist residents with meals, offer or document meal replacements when less than 50% of meals were consumed, or follow dietary restrictions for residents with special needs. In several cases, residents were left without appropriate food options or assistance, and required weight monitoring was not performed or documented as ordered.
The facility did not complete ongoing monitoring or quarterly evaluations for bed rail use for three residents, despite physician orders and care plans indicating the use of bilateral bed rails. Observations and record reviews confirmed the absence of required documentation, and the DON acknowledged that evaluations were not performed as expected.
The facility did not ensure that monthly pharmacist Medication Regimen Reviews (MRRs) and their recommendations were consistently documented in resident records or acted upon in a timely manner. For two residents receiving multiple medications, pharmacist recommendations regarding medication adjustments and necessary blood work were not acknowledged, not included in records, and not addressed for extended periods, contrary to facility policy.
A resident with a history of skin infection was administered an antibiotic for an extended period without a documented stop date or duration, despite pharmacy recommendations and facility policy requiring clarification. The antibiotic was given twice daily for nearly two months, with no evidence of provider follow-up or care plan documentation, and the Infection Preventionist was unaware of the ongoing therapy.
Surveyors found that medications, including inhalers and prescription drugs, were not properly labeled or securely stored. Opened inhalers lacked open dates, a bottle of vitamins was left at a resident's bedside without proper authorization, and a prescription medication was found unsecured in an unlocked cabinet. Staff interviews confirmed these practices did not meet required protocols.
Several residents were served unappetizing green eggs and were not offered alternate meal options when they refused or disliked the food. Staff acknowledged the issue with the eggs and confirmed that the process for offering substitutes was not consistently followed, resulting in dissatisfaction and inadequate meal intake for some residents.
Staff did not follow infection control protocols when providing care to a resident with a feeding tube, including failing to perform hand hygiene after glove removal and not donning a gown as required by EBP signage. These lapses were confirmed by both the staff involved and the DON.
The facility employed a Dietary Manager without the necessary ServSafe Manager Certification and failed to register them for the Certified Dietary Manager course, risking inadequate dietary services for residents.
The facility failed to maintain food safety and hygiene standards, risking residents' health. Observations showed improper food temperature checks, cross-contamination, inadequate hand hygiene, and delayed meal service. Unlabeled, undated, and expired foods were found in storage, with fruit flies and unclean vents adding to unsanitary conditions. The administrator acknowledged these issues.
A resident at severe risk of pressure sores developed a significant wound due to inadequate care and oversight. After a cast was removed, the facility failed to update the care plan for skin checks and brace use, leading to a deep tissue injury and exposed bone. The wound progressed to gangrene, necessitating hospital treatment and amputation. Staff interviews revealed a lack of communication and care plan updates post-cast removal.
The facility failed to obtain physician orders for COVID-19 testing for six residents and did not document test results for three residents during a COVID-19 outbreak. Staff interviews revealed a misunderstanding about the implementation of standing orders for testing.
The facility failed to respond to abuse allegations in a timely manner for two residents. One resident experienced verbal abuse from a CNA, which was not reported to administrative staff until four days later, allowing the CNA to continue working. Another resident reported an incident of physical abuse, but it was not properly documented or investigated.
Failure to fully assess and promptly respond to resident pain and ankle injury
Penalty
Summary
The facility failed to conduct a full assessment, monitor, notify the provider, and take timely action when a resident reported increased pain and later was found to have a right ankle fracture. The resident had a history of stroke, memory impairment, partial paralysis, and muscle weakness, and was dependent on staff for all mobility transfers and ADLs. The care plan directed staff to observe, report, and evaluate changes in the resident’s usual routine and notify the provider if pain was a significant change from prior experience, and the facility’s pain policy required assessment for pain indicators with changes in condition and collaboration with the provider to manage pain. After staff were told the resident had increased pain and the resident reported pain in the right leg area, the RN documented only a check of the right knee with no swelling and did not document a full assessment of the leg, assessment of other body parts, or notification of the provider. Later that evening, an LPN assessed severe pain with the right ankle swollen, red, and warm to touch and sent the resident to the hospital, where imaging showed a right ankle fracture. The resident stated they heard a popping noise during care, reported acute pain, and remained in severe pain for several hours before hospital transfer. The family member stated the RN did not assess the full leg and that the resident waited all day in pain before receiving proper care.
Failure to Provide Required Transfer Notifications, Bed Hold Policies, and Communication During Resident Transfers
Penalty
Summary
Facility staff failed to provide required written transfer notifications, bed hold policies, and call reports to the receiving hospital for multiple residents who were transferred to acute care hospitals. For several residents, there was no documentation that written transfer notices were given to the residents or their representatives at the time of transfer, nor were copies of these notices found in the residents' records. In some cases, residents or their representatives reported not receiving timely notification or explanation regarding the transfer, and staff interviews confirmed that these notifications were not provided as required. Additionally, the facility did not consistently offer or document bed hold policies to residents or their representatives during hospital transfers. In instances where residents declined bed holds, the forms lacked a witness staff signature to verify verbal consent. The facility also failed to document that staff called and reported the residents' medical status to the receiving hospital at the time of transfer for several residents, as expected for continuity of care. The report further notes that the Office of the State Long Term Care Ombudsman (LTCO) was not notified for certain resident transfers, and in one case, the resident's medical provider was not notified of a discharge. Staff interviews confirmed these omissions, and staff acknowledged the importance of these notifications and documentation for resident safety and informed decision-making. The deficiencies were identified through record reviews and staff and resident representative interviews.
Unsecured Chemicals and Sharps in Resident Areas
Penalty
Summary
Multiple unsecured areas containing hazardous chemicals and sharps were observed throughout the facility, including the north and south units, soiled laundry room, and central supply room. On several occasions, doors to shower rooms, utility rooms, and storage areas were found propped open or unlocked with no staff present. Inside these areas, chemical cleaning agents, razors, scissors, and other potentially dangerous items were accessible to residents. Cabinets intended to secure these items were also found unlocked or lacking locks altogether. Staff interviews confirmed that these items should have been secured and that the rooms should have remained locked for resident safety. Facility policies required chemicals and sharps to be stored out of residents' reach and never left unattended. Despite these policies, observations revealed that chemicals, razors, and other hazardous items were left within reach in unlocked or unattended rooms. Staff acknowledged the failure to secure these items, citing broken locks and lack of cabinet locks as contributing factors. These actions and inactions resulted in the facility failing to maintain a safe environment free from accident hazards, as required by regulation.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a required Notification of Medicare Non-Coverage (NOMNC) to a resident who was admitted and later discharged to an adult family home. Record review showed no evidence that the NOMNC letter was given to the resident prior to discharge, despite the discharge being planned and documented in social services notes. During an interview, the Social Service Director confirmed that the NOMNC letter was not provided to the resident before discharge, as required by regulation.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents as required by its own policy. Observations revealed that several resident rooms in the South Wing lacked any personal items or décor, with blank walls and, in one instance, a strong odor of urine and a bedside commode containing urine. Another room was noted to be dark, with no functioning hallway light for at least two days, despite the resident reporting the issue to staff. Staff interviews confirmed awareness of these environmental deficiencies, including the lack of personalization and lighting issues, but indicated that corrective measures had not yet been implemented. Additionally, both the North and South Wings had weight scales in the shower rooms that were visibly rusted, with rust present on the ramps and safety rails, and rust dust observed on the floor. Staff acknowledged that residents could come into contact with the rust and that the equipment should be repaired or replaced. These conditions were observed during multiple site visits and confirmed through staff and resident interviews, demonstrating a failure to maintain a clean and safe environment as outlined in facility policy.
Failure to Complete Significant Change Assessment for Resident on Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of determining a significant change in condition for a resident who was reviewed following their death. Record review showed that the resident experienced a series of health declines, including increased confusion, becoming bedridden, dropping blood pressure, discontinuation of blood pressure medications, development of a new pressure ulcer, refusal of food and fluids due to difficulty swallowing, and increased pain. The resident's representative requested comfort care, and a physician order for hospice services was implemented. Despite these documented changes and the initiation of hospice care, there was no evidence that a SCSA was completed as required by the Resident Assessment Instrument (RAI) Manual. Interviews with the DON and MDS Nurse confirmed that the resident had multiple changes in condition and that a SCSA should have been completed prior to the resident's death, but it was not done. This failure was identified during the review of the resident's records and staff interviews.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the quarterly MDS indicated no falls during the assessment period, despite documentation in the nursing progress notes that the resident had experienced a fall while attempting to retrieve clothing without staff assistance. The MDS Coordinator confirmed that the fall should have been captured in the MDS, but it was not, resulting in an inaccurate assessment. For another resident, the MDS was coded as a discharge to an acute care hospital, while health records and staff interviews confirmed that the resident was actually discharged home per physician orders. The MDS Coordinator acknowledged the error, stating that the MDS should have been coded as a discharge to home/community. These inaccuracies in the MDS assessments were identified through observation, interview, and record review, and were not in accordance with the facility's policy to follow the Resident Assessment Instrument guidelines.
Failure to Obtain Required PASRR Level 2 Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained for five out of nine residents reviewed who had indications of serious mental illness (SMI). According to facility policy, a positive PASRR Level 1 screen for SMI requires a referral for a Level 2 evaluation, which should be conducted prior to admission or upon identification of new SMI diagnoses. For several residents, documentation showed either a referral for a Level 2 evaluation was made but not followed up on, or no referral was made at all despite the presence of SMI diagnoses such as depression, anxiety, psychotic disorder, and schizophrenia. In one case, a resident was referred for a Level 2 evaluation after a change in condition, but there was no evidence in the records that the evaluation was obtained or that follow-up occurred, even months after the referral. Interviews with facility staff confirmed that there was no established process for tracking or following up on PASRR Level 2 referrals to ensure completion. Staff acknowledged that residents with SMI should have been referred for Level 2 evaluations and that these evaluations are important for ensuring appropriate mental health care. Record reviews for the affected residents showed missing or incomplete PASRR Level 2 documentation, and in some cases, no updated PASRR Level 1 was completed after new mental health diagnoses were identified. These actions and omissions resulted in the facility not obtaining required PASRR Level 2 determinations for residents with SMI.
Failure to Develop Palliative Care Plan for Resident
Penalty
Summary
The facility failed to develop a Palliative care plan for one resident who was reviewed for closed records. According to the health records, a physician's progress note documented that the resident's representative had agreed to Palliative care services, but there was no corresponding Palliative care plan in the resident's file. The Director of Nursing confirmed during an interview that a Palliative care plan was not present and acknowledged that one should have been developed to guide staff in providing comfort-focused interventions at the end of life. This deficiency was identified through record review and staff interview, and was found to be inconsistent with the facility's policy requiring timely, person-centered care plans involving the resident or their representative.
Failure to Conduct Quarterly Care Conferences and Revise Care Plans
Penalty
Summary
The facility failed to conduct and document quarterly care conferences for three residents and did not ensure care plans were revised as required for two residents. For one resident with diabetes, anxiety, and depression, there was no documentation of a care conference for over two and a half years, despite a note indicating the resident declined a quarterly conference at one point, with no evidence of further offers or follow-up. Another resident in a persistent vegetative state had only a single documented attempt to schedule a care conference with their representative, with no further follow-up. A third resident, who had no memory impairment, reported not being offered or having a care conference since admission, and records confirmed no such documentation except for a single declined offer, with no further attempts noted. Additionally, the facility did not revise care plans as required for two residents. One resident with respiratory failure had a care plan that continued to include oxygen supplementation and monitoring, even after supplemental oxygen was discontinued, which was not updated in the care plan and could cause confusion. Another resident with multiple complex diagnoses, including heart failure and risk for malnutrition, repeatedly refused to be weighed as ordered by the physician. The care plan for this resident did not include specific interventions to address refusals to be weighed, nor did it document staff efforts to obtain the resident's weight, despite ongoing refusals and the importance of weight monitoring for medication management. Interviews with facility staff confirmed that the process for providing quarterly care conferences was inconsistent and not fully implemented, with some disciplines no longer attending care conferences as expected. Staff also acknowledged that care plans were not always updated to reflect changes in residents' needs or to include specific interventions for care refusals, as required by facility policy and regulatory standards.
Failure to Obtain and Follow Physician Orders for Bed Rails, Blood Sugar, and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident with diabetes, there was a lack of physician orders specifying blood sugar parameters for when to notify the physician of dangerously low levels, despite the resident receiving injectable medication for blood sugar control. Additionally, this same resident had bilateral bed rails in use without a corresponding physician order. Staff interviews confirmed that these orders were missing and acknowledged the importance of having them in place. Another resident with hypertension received blood pressure medication outside of the prescribed parameters, as staff administered the medication even when the resident's systolic blood pressure was below the threshold specified in the physician's order. For a third resident, a physician order for a diuretic included instructions to check blood pressure prior to administration, but these instructions were not transferred to the medication administration record, resulting in staff not checking blood pressure as required. Staff interviews confirmed these deficiencies and the need for clarification of orders.
Failure to Provide Required ADL Assistance and Supervision
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff support. One resident, who was moderately cognitively impaired and required total assistance for transfers, was observed repeatedly left in their wheelchair for extended periods, including while asleep, without being assisted back to bed as requested by their representative. Staff interviews confirmed that the resident was routinely kept in their wheelchair after breakfast until the afternoon, despite expectations that staff should assist residents to lie down if they were asleep in their wheelchair. Another resident, dependent on staff for bathing, dressing, and personal hygiene due to impaired balance and diabetes, reported that staff did not provide nail care, did not offer washcloths for personal hygiene, and did not remove their socks for weeks. Observations confirmed the resident had long, cracked toenails and dry, discolored skin on their feet, with one leg more swollen than the other. Staff interviews revealed that refusals of care were not documented, and the resident was not referred to the podiatrist for diabetic foot care as required, nor was there evidence of proper communication among staff regarding the resident's needs. A third resident, who had recently transitioned to hospice care and required supervision while eating, was observed multiple times with meal trays but without staff supervision during meals. On one occasion, the resident was heard coughing while eating alone, and staff did not provide the required supervision. Staff interviews indicated a lack of awareness of the resident's current care plan, with some staff believing only setup assistance was needed, despite documentation requiring supervision. These failures were contrary to the facility's own ADL policy and placed residents at risk for unmet care needs.
Failure to Ensure Lab Monitoring, Change of Condition Reporting, and Pain Medication Administration
Penalty
Summary
The facility failed to ensure appropriate laboratory testing and monitoring for several residents receiving medications that require such oversight. One resident was prescribed cholesterol-lowering and uric acid-lowering medications without any documented lab results for cholesterol or uric acid levels, and there was no diagnosis related to high uric acid. Staff acknowledged that these labs should have been obtained prior to medication administration. Another resident with hypothyroidism received daily thyroid hormone replacement without documentation of a Thyroid Stimulating Hormone (TSH) test to monitor therapy effectiveness. The facility also failed to observe and report changes in condition for residents at risk. One resident with diabetes and a history of heart failure reported that staff did not remove their socks or check their legs for swelling, resulting in undetected edema for three weeks. Another resident dependent on dialysis had redness, swelling, and pain in their right hand, which staff failed to notice or report during routine care, despite care plans instructing staff to monitor for such changes. Additionally, the facility did not administer pain medications as ordered for a resident with a history of vertebral fracture and chronic pain. The resident received a lower dose of pain medication than prescribed on multiple occasions, and a pain patch was not applied as soon as it was available, contrary to physician orders. Staff interviews confirmed that medication administration did not follow the prescribed pain management protocol.
Failure to Provide Adequate Nutrition, Meal Replacements, and Weight Monitoring
Penalty
Summary
Staff failed to provide adequate nutritional care and meal replacements for multiple residents who consumed less than 50% of their meals. In one instance, a resident who was unable to feed themselves was left with a meal tray and not assisted until nearly an hour later, by which time the food was cold. The resident consumed less than 10% of the meal, and staff did not offer or document a meal replacement, contrary to facility policy. Staff interviews confirmed that meal replacements should be offered and documented when residents consume less than half of their meal, but this was not done. Another resident with diagnoses including morbid obesity, heart failure, and malnutrition, and who was lactose intolerant and diabetic, frequently refused facility meals. Staff offered inappropriate snacks such as milk and high-sugar items, despite knowing the resident's dietary restrictions. When the resident refused meals, staff did not consistently offer suitable meal alternatives or ensure that outside food was properly stored, as required by facility policy. Staff interviews revealed uncertainty about the provision of supplements and the storage of outside food. A third resident, at risk for malnutrition and with dysphagia, had physician orders for regular weight monitoring. Staff failed to obtain and accurately document weights as ordered, with several entries missing or marked as refused without evidence of alternative attempts. Staff acknowledged the failure to follow physician orders and the need for alternative weighing methods for residents who refuse care. These deficiencies in nutritional care, meal replacement, and weight monitoring were observed and confirmed through staff interviews and record reviews.
Failure to Monitor Bed Rail Use According to Policy
Penalty
Summary
The facility failed to ensure ongoing monitoring of bed rail use for three residents who were reviewed for accident hazards. Observations showed that these residents had bilateral bed rails in use, despite their Minimum Data Set (MDS) assessments indicating that bed rails were not in use. Physician orders and care plans were present for bed rail use, but there was no documentation of ongoing monitoring or quarterly evaluations as required by facility policy. The policy specified that evaluation for bed rail use should be completed at least quarterly and with any change of condition. Record reviews for each resident confirmed the absence of documentation regarding ongoing monitoring of bed rail use. During an interview, the Director of Nursing acknowledged that the required quarterly evaluations for bed rail use had not been completed. This lack of monitoring was identified through observation, record review, and staff interview, and was cited as a failure to meet professional standards of practice.
Failure to Document and Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were consistently added to resident records and that the pharmacist's recommendations were reviewed and acted upon in a timely manner. For one resident, who was receiving multiple medications including antipsychotics, antidepressants, anticoagulants, antiplatelets, blood sugar control, and antiseizure medications, the pharmacist recommended routine blood work related to a cancer treatment medication. This recommendation was not acknowledged, not included in the resident's record, and not acted upon or discussed with the physician for over five months. Additionally, other MRRs for this resident were missing from the record, with only a few months' reports present. For another resident, who was also on several medications such as antianxiety, antidepressants, water pills, and antiplatelets, the pharmacist made recommendations to consider reducing certain medications based on blood test results. These recommendations were not documented as reviewed or addressed by staff, and were not included in the resident's record. The recommendations were not acted upon until more than two months after they were made. Staff interviews confirmed that the MRRs were not followed up on, not implemented, and not included in the residents' records as required by facility policy.
Failure to Clarify and Monitor Antibiotic Therapy Duration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, specifically regarding the continued use of an antibiotic for a chronic lower leg skin infection. The resident, who had a history of urinary tract infections and skin infection, was started on an antibiotic with a physician order that directed staff to follow up with the provider regarding the infection. However, the order did not specify a stop date or duration for the antibiotic therapy. A pharmacy medication review identified the missing stop date and duration, noting the increased risk associated with prolonged use, and recommended that the intended duration or stop date be documented. Despite this, there was no evidence that the facility provided this information or clarified the order with the provider. Medication Administration Records showed the resident received the antibiotic twice daily for nearly two months without documented reassessment or clarification of the ongoing need. Progress notes did not indicate that the provider was notified to address the missing stop date or duration. Interviews with the Infection Preventionist revealed a lack of awareness regarding the resident’s ongoing antibiotic therapy and a failure to follow up as required by the physician’s order. The antibiotic usage was also not documented on the care plan, and both nursing staff and the Infection Preventionist did not ensure appropriate follow-up with the provider.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the proper storage and labeling of medications across several areas of the facility. On one medication cart, three opened inhaler medications were found without open dates, despite staff acknowledging that inhalers should be dated upon opening and discarded after 30 days. Additionally, an opened bottle of vitamins with remaining tablets was found at a resident's bedside in one room, which staff confirmed should not occur without a physician order and proper storage. The resident in question denied knowledge of the vitamins, and staff confirmed that medications at bedside require a resident assessment, physician order, and secure storage. Further, in the 600 Hall, the shower room door was found propped open and unattended, with an overhead cabinet left unlocked containing a prescription medication labeled for a resident. Staff confirmed that such medications should be secured in the medication cart and not left accessible in an unlocked cabinet. These observations demonstrate lapses in medication management protocols, including failure to label, secure, and properly store medications as required.
Unappetizing Meals and Lack of Alternate Food Options
Penalty
Summary
The facility failed to serve meals that were appetizing in appearance and palatable, as well as to offer alternate meal options to residents who refused or disliked the food provided. Multiple residents reported dissatisfaction with the taste and appearance of their meals, specifically noting that the scrambled eggs served at breakfast were green and unappetizing. Observations confirmed that several residents did not eat the eggs, and staff acknowledged that the eggs had turned green after being placed on the steam table due to a substitute egg product being used. Staff also admitted to serving the eggs despite their appearance and stated that residents were not offered alternative meal options when they refused the food. Interviews with residents revealed that some did not receive enough food and relied on family to bring in outside meals, while others left portions of their meals uneaten due to poor quality or unappealing presentation. Staff interviews further confirmed that the process for offering alternate meals was not consistently followed, and that communication with residents regarding food-related issues was lacking. The facility's own policy required staff to offer substitutes of similar nutritive value when a resident refused a meal, but this was not implemented as observed and reported.
Failure to Follow Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow established infection control practices during the care of a resident requiring enhanced barrier precautions (EBP). Specifically, a Certified Nursing Assistant provided personal care to a resident with a feeding tube, removed soiled gloves, did not perform hand hygiene, left the room to obtain new gloves, and returned to the resident's room without performing hand hygiene before donning clean gloves. This action was observed during the provision of incontinence care. Additionally, a Registered Nurse prepared and administered feeding and medications through the resident's feeding tube without donning a gown, as required by the EBP signage and facility policy. The nurse acknowledged forgetting to wear the gown, which was expected for all staff when working with the resident's feeding tube. The Director of Nursing confirmed that staff are expected to perform hand hygiene before and after resident care and to follow EBP signage, including gowning up when directed.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Dietary Manager, referred to as Staff C, possessed the necessary training and qualifications required for the role. Staff C was employed on 08/07/2024, but did not have the ServSafe Manager Certification, which verifies sufficient food safety knowledge to protect the public from foodborne illness, as required for employment. Additionally, Staff C was not registered for the Certified Dietary Manager (CDM) course, which is essential for managing food service operations and ensuring food safety in a healthcare facility. This deficiency was identified through interviews and record reviews, placing all residents at risk of receiving dietary services from staff lacking the required competencies and skills.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, placing all 92 residents at risk of foodborne illness and poor nutritional intake. Observations revealed that food temperatures were not checked before serving, with hot foods like pork sausage and eggs being served at temperatures within the danger zone, which allows rapid bacterial growth. Staff members were unaware of the required temperature standards, and no temperature logs were maintained for the meals served on the observed dates. Cross-contamination was observed when a dietary manager placed cracked eggshells on top of whole eggs, and an energy drink spilled onto a carton of eggs. Hand hygiene practices were inadequate, with staff failing to wash hands properly after sneezing or touching potentially contaminated surfaces. Additionally, meal service was delayed, with trays leaving the kitchen later than the posted times, further compromising food safety. Food storage practices were also deficient, with unlabeled, undated, and expired foods found in the walk-in refrigerator. The presence of fruit flies in the dry storage room and unclean kitchen vents added to the unsanitary conditions. The administrator acknowledged these issues, stating that kitchen staff were expected to maintain cleanliness and adhere to food safety protocols.
Failure to Prevent Pressure Ulcer Leads to Severe Harm
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of an avoidable pressure ulcer for a resident, leading to significant harm. The resident, who was at severe risk of developing pressure sores, had a hard cast on their right lower extremity due to a surgically repaired ankle fracture. Despite being assessed as at risk, the care plan was not updated after the cast was removed, and the resident was transitioned to a lace-up brace. The facility did not perform adequate skin checks or clarify with the orthopedic provider about the brace's use and the need for range of motion exercises. The resident developed a deep tissue injury and an open wound on their right foot, which was attributed to pressure from their preferred lying position. The wound was not identified until it had progressed significantly, resulting in exposed bone and gangrene. The facility's investigation noted that the resident always had their leg wrapped, and staff did not remove the brace for skin checks, leading to the oversight of the developing wound. Interviews with staff revealed a lack of communication and understanding regarding the resident's care needs post-cast removal. The Director of Nursing acknowledged that the care plan was not revised to include necessary skin checks after the cast was removed. The resident's condition deteriorated to the point of requiring hospital treatment and an above-the-knee amputation due to the severity of the wound.
Failure to Obtain Physician Orders and Document COVID-19 Test Results
Penalty
Summary
The facility failed to obtain laboratory services according to professional standards of practice for eight residents reviewed for COVID-19 testing. Specifically, the facility did not obtain physician orders (POs) for COVID-19 testing for six residents and failed to document the results of the testing for three residents. This deficiency was identified during a COVID-19 outbreak in the facility, which began on April 20, 2024. The Director of Nursing (Staff B) confirmed that the facility was conducting COVID-19 testing twice a week during the outbreak, but the necessary POs were not in place for several residents, and test results were not consistently documented. For Resident 1, there were no POs for COVID-19 testing, although tests were performed on multiple dates with negative results. Resident 2 also lacked POs but had multiple tests performed, with one positive result leading to transmission-based precautions. Resident 3 and Resident 4 had no POs but had tests performed with varying results. Resident 5 had a change of condition and was diagnosed with COVID-19 in the emergency room, but the facility did not document the test results upon return. Resident 6 had a PO for a test that was not documented as done, and another test was performed without an associated PO. Residents 7 and 8 had POs for tests, but the results were not documented. Staff interviews revealed a misunderstanding about the implementation of standing orders for COVID-19 testing.
Failure to Respond to Abuse Allegations in a Timely Manner
Penalty
Summary
The facility failed to respond to abuse allegations in a timely manner for two residents. For Resident 1, the incident occurred when a CNA verbally abused the resident during a night shift. The abuse was reported by another CNA to a nurse after the shift ended, but neither the reporting CNA nor the nurse followed up or reported the allegation to the administrative staff until four days later. During this period, the alleged perpetrator continued to work with residents. The facility only assessed Resident 1 for injury and notified their family and physician four days after the incident was reported. The CNA involved was eventually suspended and terminated, but not before working additional shifts. For Resident 8, the resident reported an incident where a man grabbed them from behind, placed them on the ground, and pulled down their shorts. This incident was documented in a behavior note, but no report was made in the incident reporting log, and the Director of Nursing was not made aware of the allegation. The staff's response was limited to reorienting the resident and offering them a cup of coffee and a quiet space. The Director of Nursing acknowledged that the staff did not follow the proper process for reporting and investigating the allegation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Federal Way
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Care Center Federal Way, L.l.c. | 0.8 mi | ★★★★★ | 26 | 0 |
| Garden Terrace Healthcare Center Of Federal Way | 0.9 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Federal Way | 1.1 mi | ★★★★★ | 1 | 0 |
| Auburn Post Acute | 5.3 mi | ★★★★★ | 12 | 2 |
| North Auburn Care | 5.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.